Philippine Nursing Board Exam (NLE) Questions - Answer: (A) Administers medications to a

Psychiatric Nursing
schizophrenic patient.
1. Mental health is defined as:
Administration of medications and treatments,
A. The ability to distinguish what is real from what is
assessment, documentation are the activities of the
not.
nurse as a technician. B. Activities as a parent
B. A state of well-being where a person can realize
surrogate. C. Refers to the ward manager role. D.
his own abilities can cope with normal stresses of life
Role as a teacher.
and work productively.
C. Is the promotion of mental health, prevention of
3. Liza says, “Give me 10 minutes to recall the name
mental disorders, nursing care of patients during
of our college professor who failed many students in
illness and rehabilitation
our anatomy class.” She is operating on her:
D. Absence of mental illness
A. Subconscious
B. Conscious
Answer: (B) A state of well-being where a person can
C. Unconscious
realize his own abilities can cope with normal
D. Ego
stresses of life and work productively.
Mental health is a state of emotional and
Answer: (A) Subconscious
psychosocial well being. A mentally healthy
Subconscious refers to the materials that are partly
individual is self aware and self directive, has the
remembered partly forgotten but these can be
ability to solve problems, can cope with crisis
recalled spontaneously and voluntarily. B. This
without assistance beyond the support of family and
functions when one is awake. One is aware of his
friends fulfill the capacity to love and work and sets
thoughts, feelings actions and what is going on in the
goals and realistic limits. A. This describes the ego
environment. C. The largest potion of the mind that
function reality testing. C. This is the definition of
contains the memories of one’s past particularly the
Mental Health and Psychiatric Nursing. D. Mental
unpleasant. It is difficult to recall the unconscious
health is not just the absence of mental illness.
content. D. The conscious self that deals and tests
reality.
2. Which of the following describes the role of a
technician?
4. The superego is that part of the psyche that:
A. Administers medications to a schizophrenic
A. Uses defensive function for protection.
patient.
B. Is impulsive and without morals.
B. The nurse feeds and bathes a catatonic client
C. Determines the circumstances before making
C. Coordinates diverse aspects of care rendered to
decisions.
the patient
D. The censoring portion of the mind.
D. Disseminates information about alcohol and its
effects.
Answer: (D) The censoring portion of the mind.
The critical censoring portion of one’s personality;
the conscience. A. This refers to the ego function Answer: (A) “Are you being threatened or hurt by
that protects itself from anything that threatens it.. your partner?
B. The Id is composed of the untamed, primitive The nurse validates her observation by asking
drives and impulses. C. This refers to the ego that simple, direct question. This also shows empathy. B,
acts as the moderator of the struggle between the id C, and D are indirect questions which may not lead
and the superego. to the discussion of abuse.
5. Primary level of prevention is exemplified by: 7. The wife admits that she is a victim of abuse and
A. Helping the client resume self care. opens up about her persistent distaste for sex. This
B. Ensuring the safety of a suicidal client in the sexual disorder is:
institution. A. Sexual desire disorder
C. Teaching the client stress management B. Sexual arousal Disorder
techniques C. Orgasm Disorder
D. Case finding and surveillance in the community D. Sexual Pain Disorder

Answer: (C) Teaching the client stress management Answer: (A) Sexual desire disorder
techniques Has little or no sexual desire or has distaste for sex.
Primary level of prevention refers to the promotion B. Failure to maintain the physiologic requirements
of mental health and prevention of mental illness. for sexual intercourse. C. Persistent and recurrent
This can be achieved by rendering health teachings inability to achieve an orgasm. D. Also called
such as modifying ones responses to stress. A. This is dyspareunia. Individuals with this disorder suffer
tertiary level of prevention that deals with genital pain before, during and after sexual
rehabilitation. B and D. Secondary level of intercourse.
prevention which involves reduction of actual illness 8. What would be the best approach for a wife who
through early detection and treatment of illness. is still living with her abusive husband?
6. Situation: In a home visit done by the nurse, she A. “Here’s the number of a crisis center that you can
suspects that the wife and her child are victims of call for help .”
abuse. B. “Its best to leave your husband.”
C. “Did you discuss this with your family?”
Which of the following is the most appropriate for D. “ Why do you allow yourself to be treated this
the nurse to ask? way”
A. “Are you being threatened or hurt by your
partner? Answer: (A) “Here’s the number of a crisis center
B. “Are you frightened of you partner” that you can call for help .”
C. “Is something bothering you?” Protection is a priority concern in abuse. Help the
D. “What happens when you and your partner victim to develop a plan to ensure safety. B. Do not
argue?” give advice to leave the abuser. Making decisions for
the victim further erodes her esteem. However
discuss options available. C. The victim tends to The client has which somatoform disorder?
isolate from friends and family. D. This is judgmental. A. Somatization Disorder
Avoid in anyway implying that she is at fault. B. Hypochondriaisis
9. Which comment about a 3 year old child if made C. Conversion Disorder
by the parent may indicate child abuse? D. Somatoform Pain Disorder
A. “Once my child is toilet trained, I can still expect
her to have some" Answer: (D) Somatoform Pain Disorder
B. “When I tell my child to do something once, I This is characterized by severe and prolonged pain
don’t expect to have to tell" that causes significant distress. A. This is a chronic
C. “My child is expected to try to do things such as, syndrome of somatic symptoms that cannot be
dress and feed.” explained medically and is associated with
D. “My 3 year old loves to say NO.” psychosocial distress. B. This is an unrealistic
preoccupation with a fear of having a serious illness.
Answer: (B) “When I tell my child to do something C. Characterized by alteration or loss in sensory or
once, I don’t expect to have to tell" motor function resulting from a
Abusive parents tend to have unrealistic psychological conflict.
expectations on the child. A,B and C are realistic 12. Freud explains anxiety as:
expectations on a 3 year old. A. Strives to gratify the needs for satisfaction and
10. The primary nursing intervention for a victim of security
child abuse is: B. Conflict between id and superego
A. Assess the scope of the problem C. A hypothalamic-pituitary-adrenal reaction to
B. Analyze the family dynamics stress
C. Ensure the safety of the victim D. A conditioned response to stressors
D. Teach the victim coping skills
Answer: (B) Conflict between id and superego
Answer: (C) Ensure the safety of the victim Freud explains anxiety as due to opposing action
The priority consideration is the safety of the victim. drives between the id and the superego. A. Sullivan
Attend to the physical injuries to ensure the identified 2 types of needs, satisfaction and security.
physiologic safety and integrity of the child. Failure to gratify these needs may result in anxiety.
Reporting suspected case of abuse may deter C. Biomedical perspective of anxiety. D. Explanation
recurrence of abuse. A,B and D may of anxiety using the behavioral model.
be addressed later. 13. The following are appropriate nursing diagnosis
11. Situation: A 30 year old male employee for the client EXCEPT:
frequently complains of low back pain that leads to A. Ineffective individual coping
frequent absences from work. Consultation and tests B. Alteration in comfort, pain
reveal negative results. C. Altered role performance
D. Impaired social interaction
 feelings. D. Giving undue attention to the physical
Answer: (D) Impaired social interaction symptom reinforces the complaint.
The client may not have difficulty in social exchange. 16. Situation: A nurse may encounter children with
The cues do not support this diagnosis. A. The client mental disorders. Her knowledge of these various
maladaptively uses body symptoms to manage disorders is vital.
anxiety. B. The client will have discomfort due to
pain. C. The client may fail to meet environmental When planning school interventions for a child with
expectations due to pain. a diagnosis of attention deficit hyperactivity
14. The following statements describe somatoform disorder, a guide to remember is to:
disorders: A. provide as much structure as possible for the child
A. Physical symptoms are explained by organic B. ignore the child’s overactivity.
causes C. encourage the child to engage in any play activity
B. It is a voluntary expression of psychological to dissipate energy
conflicts D. remove the child from the classroom when
C. Expression of conflicts through bodily symptoms disruptive behavior occurs
D. Management entails a specific medical treatment
Answer: (A) provide as much structure as possible
Answer: (C) Expression of conflicts through bodily for the child
symptoms Decrease stimuli for behavior control thru an
Bodily symptoms are used to handle conflicts. A. environment that is free of distractions, a calm non –
Manifestations do not have an organic basis. B. This confrontational approach and setting limit to time
occurs unconsciously. D. Medical treatment is not allotted for activities. B. The child will not benefit
used because the disorder does not have a structural from a lenient approach. C. Dissipate energy through
or organic basis. safe activities. D. This indicates that the classroom
15. What would be the best response to the client’s environment lacks structure.
repeated complaints of pain: 17. The child with conduct disorder will likely
A. “I know the feeling is real tests revealed negative demonstrate:
results.” A. Easy distractibility to external stimuli.
B. . “I think you’re exaggerating things a little bit.” B. Ritualistic behaviors
C. “Try to forget this feeling and have activities to C. Preference for inanimate objects.
take it off your mind” D. Serious violations of age related norms.
D. “So tell me more about the pain”
Answer: (D) Serious violations of age related norms.
Answer: (A) “I know the feeling is real tests revealed This is a disruptive disorder among children
negative results.” characterized by more serious violations of social
Shows empathy and offers information. B. This is a standards such as aggression, vandalism, stealing,
demeaning statement. C. This belittles the client’s lying and truancy. A. This is characteristic of
attention deficit disorder. B and C. These are noted and interaction skills. She has an I.Q. of 45. She is
among children with autistic disorder. diagnosed to have Mental retardation of this
18. Ritalin is the drug of choice for chidren with classification:
ADHD. The side effects of the following may be A. Profound
noted: B. Mild
A. increased attention span and concentration C. Moderate
B. increase in appetite D. Severe
C. sleepiness and lethargy
D. bradycardia and diarrhea Answer: (C) Moderate
The child with moderate mental retardation has an
Answer: (A) increased attention span and I.Q. of 35-50 Profound Mental retardation has an I.Q.
concentration of below 20; Mild mental retardation 50-70 and
The medication has a paradoxic effect that decrease Severe mental retardation has an I.Q. of 20-35.
hyperactivity and impulsivity among children with 21. The nurse teaches the parents of a mentally
ADHD. B, C, D. Side effects of Ritalin include retarded child regarding her care. The following
anorexia, insomnia, diarrhea and irritability. guidelines may be taught except:
19. School phobia is usually treated by: A. overprotection of the child
A. Returning the child to the school immediately B. patience, routine and repetition
with family support. C. assisting the parents set realistic goals
B. Calmly explaining why attendance in school is D. giving reasonable compliments
necessary
C. Allowing the child to enter the school before the Answer: (A) overprotection of the child
other children The child with mental retardation should not be
D. Allowing the parent to accompany the child in the overprotected but need protection from injury and
classroom the teasing of other children. B,C, and D Children
with mental retardation have learning difficulty.
Answer: (A) Returning the child to the school They should be taught with patience and repetition,
immediately with family support. start from simple to complex, use visuals and
Exposure to the feared situation can help in compliment them for motivation. Realistic
overcoming anxiety. A. This will not help in relieving expectations should be set and optimize their
the anxiety due separation from a significant other. capability.
C. and C. Anxiety in school phobia is not due to being 22. The parents express apprehensions on their
in school but due to separation from ability to care for their maladaptive child. The nurse
parents/caregivers so these interventions are not identifies what nursing diagnosis:
applicable. D. This will not help the child overcome A. hopelessness
the fear B. altered parenting role
20. A 10 year old child has very limited vocabulary C. altered family process
D. ineffective coping
Answer: (D) Rearrange the environment to activate
Answer: (B) altered parenting role the child
Altered parenting role refers to the inability to The child with autistic disorder does not want
create an environment that promotes optimum change. Maintaining a consistent environment is
growth and development of the child. This is therapeutic. A. Angry outburst can be rechannelled
reflected in the parent’s inability to care for the through safe activities. B. Acceptance enhances a
child. A. This refers to lack of choices or inability to trusting relationship. C. Ensure safety from self-
mobilize one’s resources. C. Refers to change in destructive behaviors like head banging and hair
family relationship and function. D. Ineffective pulling.
coping is the inability to form valid appraisal of the 25. According to Piaget a 5 year old is in what stage
stressor or inability to use available resources of development:
23. A 5 year old boy is diagnosed to have autistic A. Sensory motor stage
disorder. B. Concrete operations
Which of the following manifestations may be noted C. Pre-operational
in a client with autistic disorder? D. Formal operation

A. argumentativeness, disobedience, angry outburst Answer: (C) Pre-operational

B. intolerance to change, disturbed relatedness, Pre-operational stage (2-7 years) is the stage when
stereotypes the use of language, the use of symbols and the
C. distractibility, impulsiveness and overactivity concept of time occur. A. Sensory-motor stage (0-2
D. aggression, truancy, stealing, lying years) is the stage when the child uses the senses in
learning about the self and the environment through
Answer: (B) intolerance to change, disturbed exploration. B. Concrete operations (7-12 years)
relatedness, stereotypes when inductive reasoning develops. D. Formal
These are manifestations of autistic disorder. A. operations (2 till adulthood) is when abstract
These manifestations are noted in Oppositional thinking and deductive reasoning develop.
Defiant Disorder, a disruptive disorder among 26. Situation : The nurse assigned in the
children. C. These are manifestations of Attention detoxification unit attends to various patients with
Deficit Disorder D. These are the manifestations of substance-related disorders.
Conduct Disorder
24. The therapeutic approach in the care of an A 45 years old male revealed that he experienced a
autistic child include the following EXCEPT: marked increase in his intake of alcohol to achieve
A. Engage in diversionary activities when acting -out the desired effect This indicates:
B. Provide an atmosphere of acceptance A. withdrawal
C. Provide safety measures B. tolerance
D. Rearrange the environment to activate the child C. intoxication
D. psychological dependence Answer: (A) Monitoring his vital signs every hour
Pulse and blood pressure are usually elevated during
Answer: (B) tolerance withdrawal, Elevation may indicate impending
tolerance refers to the increase in the amount of the delirium tremens B. Client needs quiet, well lighted,
substance to achieve the same effects. A. consistent and secure environment. Excessive
Withdrawal refers to the physical signs and stimulation can aggravate anxiety and cause illusions
symptoms that occur when the addictive substance and hallucinations. C. Adequate nutrition with
is reduced or withheld. B. Intoxication refers to the sulpplement of Vit. B should be ensured. D.
behavioral changes that occur upon recent ingestion Sedatives are used to relieve anxiety.
of a substance. D. Psychological dependence refers 29. Another client is brought to the emergency room
to the intake of the substance to prevent the onset by friends who state that he took something an hour
of withdrawal symptoms. ago. He is actively hallucinating, agitated, with
27. The client admitted for alcohol detoxification irritated nasal septum.
develops increased tremors, irritability, hypertension A. Heroin
and fever. The nurse should be alert for impending: B. cocaine
A. delirium tremens C. LSD
B. Korsakoff’s syndrome D. marijuana
C. esophageal varices
D. Wernicke’s syndrome Answer: (B) cocaine
The manifestations indicate intoxication with
Answer: (A) delirium tremens cocaine, a CNS stimulant. A. Intoxication with
Delirium Tremens is the most extreme central heroine is manifested by euphoria then impairment
nervous system irritability due to withdrawal from in judgment, attention and the presence of papillary
alcohol B. This refers to an amnestic syndrome constriction. C. Intoxication with hallucinogen like
associated with chronic alcoholism due to a LSD is manifested by grandiosity, hallucinations,
deficiency in Vit. B C. This is a complication of liver synesthesia and increase in vital signs D. Intoxication
cirrhosis which may be secondary to alcoholism . D. with Marijuana, a cannabinoid is manifested by
This is a complication of alcoholism characterized by sensation of slowed time, conjunctival redness,
irregularities of eye movements and lack of social withdrawal, impaired judgment and
coordination. hallucinations.
28. The care for the client places priority to which of 30. A client is admitted with needle tracts on his
the following: arm, stuporous and with pin point pupil will likely be
A. Monitoring his vital signs every hour managed with:
B. Providing a quiet, dim room A. Naltrexone (Revia)
C. Encouraging adequate fluids and nutritious foods B. Narcan (Naloxone)
D. Administering Librium as ordered C. Disulfiram (Antabuse)
D. Methadone (Dolophine)
 Answer: (C) “This must be difficult for you and your
Answer: (B) Narcan (Naloxone) mother.”
Narcan is a narcotic antagonist used to manage the This reflecting the feeling of the daughter that shows
CNS depression due to overdose with heroin. A. This empathy. A and D. Giving advise does not encourage
is an opiate receptor blocker used to relieve the verbalization. B. This response does not encourage
craving for heroine C. Disulfiram is used as a verbalization of feelings.
deterrent in the use of alcohol. D. Methadone is 33. The primary nursing intervention in working with
used as a substitute in the withdrawal from heroine a client with moderate stage dementia is ensuring
31. Situation: An old woman was brought for that the client:
evaluation due to the hospital for evaluation due to A. receives adequate nutrition and hydration
increasing forgetfulness and limitations in daily B. will reminisce to decrease isolation
function. C. remains in a safe and secure environment
D. independently performs self care
The daughter revealed that the client used her
toothbrush to comb her hair. She is manifesting: Answer: (C) remains in a safe and secure
A. apraxia environment
B. aphasia Safety is a priority consideration as the client’s
C. agnosia cognitive ability deteriorates.. A is appropriate
D. amnesia interventions because the client’s cognitive
impairment can affect the client’s ability to attend to
Answer: (C) agnosia his nutritional needs, but it is not the priority B.
This is the inability to recognize objects. A. Apraxia is Patient is allowed to reminisce but it is not the
the inability to execute motor activities despite priority. D. The client in the moderate stage of
intact comprehension. B. Aphasia is the loss of ability Alzheimer’s disease will have difficulty in performing
to use or understand words. D. Amnesia is loss of activities independently
memory. 34. She says to the nurse who offers her breakfast,
32. She tearfully tells the nurse “I can’t take it when “Oh no, I will wait for my husband. We will eat
she accuses me of stealing her things.” Which together” The therapeutic response by the nurse is:
response by the nurse will be most therapeutic? A. “Your husband is dead. Let me serve you your
A. ”Don’t take it personally. Your mother does not breakfast.”
mean it.” B. “I’ve told you several times that he is dead. It’s
B. “Have you tried discussing this with your time to eat.”
mother?” C. “You’re going to have to wait a long time.”
C. “This must be difficult for you and your mother.” D. “What made you say that your husband is alive?
D. “Next time ask your mother where her things
were last seen.” Answer: (A) “Your husband is dead. Let me serve you
your breakfast.”
The client should be reoriented to reality and be B. Do a short term exercise until the urge passes
focused on the here and now.. B. This is not a helpful C. Approach the nurse and talk out her feelings
approach because of the short term memory of the D. Call her mother on the phone and tell her how
client. C. This indicates a pompous response. D. The she feels
cognitive limitation of the client makes the client
incapable of giving explanation. Answer: (C) Approach the nurse and talk out her
35. Dementia unlike delirium is characterized by: feelings
A. slurred speech The client with anorexia nervosa uses starvation as a
B. insidious onset way of managing anxiety. Talking out feelings with
C. clouding of consciousness the nurse is an adaptive coping. A. Starvation should
D. sensory perceptual change not be encouraged. Physical safety is a priority.
Without adequate nutrition, a life threatening
Answer: (B) insidious onset situation exists. B. The client with anorexia nervosa
Dementia has a gradual onset and progressive is preoccupied with losing weight due to disturbed
deterioration. It causes pronounced memory and body image. Limits should be set on attempts to lose
cognitive disturbances. A,C and D are all more weight. D. The client may have a domineering
characteristics of delirium. mother which causes the client to feel ambivalent.
36. Situation: A 17 year old gymnast is admitted to The client will not discuss her feelings with her
the hospital due to weight loss and dehydration mother.
secondary to starvation. 38. The client with anorexia nervosa is improving if:
A. She eats meals in the dining room.
Which of the following nursing diagnoses will be B. Weight gain
given priority for the client? C. She attends ward activities.
A. altered self-image D. She has a more realistic self concept.
B. fluid volume deficit
C. altered nutrition less than body requirements Answer: (B) Weight gain
D. altered family process Weight gain is the best indication of the client’s
improvement. The goal is for the client to gain 1-2
Answer: (B) fluid volume deficit pounds per week. (A)The client may purge after
Fluid volume deficit is the priority over altered eating. (C) Attending an activity does not indicate
nutrition (A) since the situation indicates that the improvement in nutritional state. (D) Body image is a
client is dehydrated. A and D are psychosocial needs factor in anorexia nervosa but it is not an indicator
of a client with anorexia nervosa but they are not for improvement.
the priority. 39. The characteristic manifestation that will
37. What is the best intervention to teach the client differentiate bulimia nervosa from anorexia nervosa
when she feels the need to starve? is that bulimic individuals
A. Allow her to starve to relieve her anxiety A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight promote a therapeutic relationship
C. have peculiar food handling patterns 42. Situation: A 35 year old male has intense fear of
D. have threatened self-esteem riding an elevator. He claims “ As if I will die inside.”
This has affected his studies
Answer: (A) have episodic binge eating and purging
Bulimia is characterized by binge eating which is The client is suffering from:
characterized by taking in a large amount of food
over a short period of time. B and C are
characteristics of a client with anorexia nervosa D. A. agoraphobia
Low esteem is noted in both eating disorders B. social phobia
40. A nursing diagnosis for bulimia nervosa is C. Claustrophobia
powerlessness related to feeling not in control of D. xenophobia
eating habits. The goal for this problem is:
A. Patient will learn problem solving skills Answer: (C) Claustrophobia
B. Patient will have decreased symptoms of anxiety. Claustrophobia is fear of closed space. A.
C. Patient will perform self care activities daily. Agoraphobia is fear of open space or being a
D. Patient will verbalize how to set limits on others. situation where escape is difficult. B. Social phobia is
fear of performing in the presence of others in a way
Answer: (A) Patient will learn problem solving skills that will be humiliating or embarrassing. D.
if the client learns problem solving skills she will gain Xenophobia is fear of strangers.
a sense of control over her life. (B) Anxiety is caused 43. Initial intervention for the client should be to:
by powerlessness. (C) Performing self care activities A. Encourage to verbalize his fears as much as he
will not decrease ones powerlessness (D) Setting wants.
limits to control imposed by others is a necessary B. Assist him to find meaning to his feelings in
skill but problem solving skill is the priority. relation to his past.
41. In the management of bulimic patients, the C. Establish trust through a consistent approach.
following nursing interventions will promote a D. Accept her fears without criticizing.
therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust Answer: (D) Accept her fears without criticizing.
B. Discuss their eating behavior. The client cannot control her fears although the
C. Help patients identify feelings associated with client knows its silly and can joke about it. A. Allow
binge-purge behavior expression of the client’s fears but he should focus
D. Teach patient about bulimia nervosa on other productive activities as well. B and C. These
are not the initial interventions.
Answer: (B) Discuss their eating behavior. 44. The nurse develops a countertransference
The client is often ashamed of her eating behavior. reaction. This is evidenced by:
Discussion should focus on feelings. A,C and D A. Revealing personal information to the client
B. Focusing on the feelings of the client. Valium is a CNS depressant. Taking it with other CNS
C. Confronting the client about discrepancies in depressants like alcohol; potentiates its effect. B.
verbal or non-verbal behavior The client should be taught to avoid activities that
D. The client feels angry towards the nurse who require alertness. C. Valium causes dry mouth so the
resembles his mother. client must increase her fluid intake. D. Stimulants
must not be taken by the client because it can
Answer: (A) Revealing personal information to the decrease the effect of Valium.
client 47. Situation: A 20 year old college student is
A. Countertransference is an emotional reaction of admitted to the medical ward because of sudden
the nurse on the client based on her unconscious onset of paralysis of both legs. Extensive
needs and conflicts. B and C. These are therapeutic examination revealed no physical basis for the
approaches. D. This is transference reaction where a complaint.
client has an emotional reaction towards the nurse
based on her past. The nurse plans intervention based on which correct
45. Which is the desired outcome in conducting statement about conversion disorder?
desensitization: A. The symptoms are conscious effort to control
A. The client verbalize his fears about the situation anxiety
B. The client will voluntarily attend group therapy in B. The client will experience high level of anxiety in
the social hall. response to the paralysis.
C. The client will socialize with others willingly C. The conversion symptom has symbolic meaning to
D. The client will be able to overcome his disabling the client
fear. D. A confrontational approach will be beneficial for
the client.
Answer: (D) The client will be able to overcome his
disabling fear. Answer: (C) The conversion symptom has symbolic
The client will overcome his disabling fear by gradual meaning to the client
exposure to the feared object. A,B and C are not the the client uses body symptoms to relieve anxiety. A.
desired outcome of desensitization. The condition occurs unconsciously. B. The client is
46. Which of the following should be included in the not distressed by the lost or altered body function.
health teachings among clients receiving Valium: D. The client should not be confronted by the
A. Avoid taking CNS depressant like alcohol. underlying cause of his condition because this can
B. There are no restrictions in activities. aggravate the client’s anxiety.
C. Limit fluid intake. 48. Nina reveals that the boyfriend has been
D. Any beverage like coffee may be taken pressuring her to engage in premarital sex. The most
therapeutic response by the nurse is:
Answer: (A) Avoid taking CNS depressant like A. “I can refer you to a spiritual counselor if you
alcohol. like.”
B. “You shouldn’t allow anyone to pressure you into Stree management techniques is the best
sex.” management of somatoform disorder because the
C. “It sounds like this problem is related to your disorder is related to stress and it does not have a
paralysis.” medical basis. A. This disorder is not supported by
D. “How do you feel about being pressured into sex organic pathology so no medical regimen is required.
by your boyfriend?” B and D. Milieu therapy and psychotherapy may be
used a therapeutic modalities but these are not the
Answer: (D) “How do you feel about being pressured best.
into sex by your boyfriend?” 51. Which is the best indicator of success in the long
Focusing on expression of feelings is therapeutic. term management of the client?
The central force of the client’s condition is anxiety. A. His symptoms are replaced by indifference to his
A. This is not therapeutic because the nurse passes feelings
the responsibility to the counselor. B. Giving advice B. He participates in diversionary activities.
is not therapeutic. C. This is not therapeutic because C. He learns to verbalize his feelings and concerns
it confronts the underlying cause. D. He states that his behavior is irrational.
49. Malingering is different from somatoform
disorder because the former: Answer: (C) He learns to verbalize his feelings and
A. Has evidence of an organic basis. concerns
B. It is a deliberate effort to handle upsetting events C. The client is encouraged to talk about his feelings
C. Gratification from the environment are obtained. and concerns instead of using body symptoms to
D. Stress is expressed through physical symptoms. manage his stressors. A. The client is encouraged to
acknowledge feelings rather than being indifferent
Answer: (B) It is a deliberate effort to handle to her feelings. B. Participation in activities diverts
upsetting events the client’s attention away from his bodily concerns
Malingering is a conscious simulation of an illness but this is not the best indicator of success. D. Help
while somatoform disorder occurs unconscious. A. the client recognize that his physical symptoms
Both disorders do not have an organic or structural occur because of or are exacerbated by specific
basis. C. Both have primary gains. D. This is a stressor, not as irrational.
characteristic of somatoform disorder. 52. Situation: A young woman is brought to the
50. Unlike psychophysiologic disorder Linda may be emergency room appearing depressed. The nurse
best managed with: learned that her child died a year ago due to an
A. medical regimen accident.
B. milieu therapy
C. stress management techniques The initial nursing diagnosis is dysfunctional grieving.
D. psychotherapy The statement of the woman that supports this
diagnosis is:
Answer: (C) stress management techniques
 54. The following medications will likely be
A. “I feel envious of mothers who have toddlers” prescribed for the client EXCEPT:
B. “I haven’t been able to open the door and go into A. Prozac
my baby’s room “ B. Tofranil
C. “I watch other toddlers and think about their play C. Parnate
activities and I cry.” D. Zyprexa
D. “I often find myself thinking of how I could have
prevented the death. Answer: (D) Zyprexa
This is an antipsychotic. A. This is a SSRI
Answer: (B) “I haven’t been able to open the door antidepressant. B. This antidepressant belongs to the
and go into my baby’s room “ Tricyclic group. C. This is a MAOI antidepressant.
This indicates denial. This defense is adaptive as an 55. Which is the highest priority in the post ECT
initial reaction to loss but an extended, unsuccessful care?
use of denial is dysfunctional. A. This indicates A. Observe for confusion
acknowledgement of the loss. Expressing feelings B. Monitor respiratory status
openly is acceptable. C. This indicates the stage of C. Reorient to time, place and person
depression in the grieving process. D. Remembering D. Document the client’s response to the treatment
both positive and negative aspects of the deceased
love one signals successful mourning. Answer: (B) Monitor respiratory status
53. The client said “I can’t even take care of my A side effect of ECT which is life threatening is
baby. I’m good for nothing.” Which is the respiratory arrest. A and C. Confusion and
appropriate nursing diagnosis? disorientation are side effects of ECT but these are
A. Ineffective individual coping related to loss. not the highest priority.
B. Impaired verbal communication related to 56. Situation: A 27 year old writer is admitted for the
inadequate social skills. second time accompanied by his wife. He is
C. Low esteem related to failure in role performance demanding, arrogant talked fast and hyperactive.
D. Impaired social interaction related to repressed
anger. Initially the nurse should plan this for a manic client:

Answer: (C) Low esteem related to failure in role A. set realistic limits to the client’s behavior
performance B. repeat verbal instructions as often as needed
This indicates the client’s negative self evaluation. A C. allow the client to get out feelings to relieve
sense of worthlessness may accompany depression. tension
A,B and D are not relevant. The cues do not indicate D. assign a staff to be with the client at all times to
inability to use coping resources, decreased ability to help maintain control
transmit/process symbols, nor insufficient quality of
social exchange Answer: (A) set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in the weakness in others or create conflicts among the
injurious activities. A quiet environment and staff. Bargaining should not be allowed. B. This is not
consistent and firm limits should be set to ensure therapeutic because the client tends to control and
safety. B. Clear, concise directions are given because dominate others. C. Limits are set for interaction
of the distractibility of the client but this is not the time. D. Allowing the client to negotiate may
priority. C. The manic client tend to externalize reinforce manipulative behavior.
hostile feelings, however only non-destructive 59. The nurse exemplifies awareness of the rights of
methods of expression should be allowed D. Nurses a client whose anger is escalating by:
set limit as needed. Assigning a staff to be with the A. Taking a directive role in verbalizing feelings
client at all times is not realistic. B. Using an authoritarian, confrontational approach
57. An activity appropriate for the client is: C. Putting the client in a seclusion room
A. table tennis D. Applying mechanical restraints
B. painting
C. chess Answer: (A) Taking a directive role in verbalizing
D. cleaning feelings
The client has the right to be free from unnecessary
Answer: (D) cleaning restraints. Verbalization of feelings or “talking down”
The client’s excess energy can be rechanelled in a non-threatening environment is helpful to
through physical activities that are not competitive relieve the client’s anger. B. This is a threatening
like cleaning. This is also a way to dissipate tension. approach. C and D. Seclusion and application
A. Tennis is a competitive activity which can restraints are done only when less restrictive
stimulate the client. measures have failed to contain the client’s anger.
58. The client is arrogant and manipulative. In 60. A client on Lithium has diarrhea and vomiting.
ensuring a therapeutic milieu, the nurse does one of What should the nurse do first:
the following: A. Recognize this as a drug interaction
A. Agree on a consistent approach among the staff B. Give the client Cogentin
assigned to the client. C. Reassure the client that these are common side
B. Suggest that the client take a leading role in the effects of lithium therapy
social activities D. Hold the next dose and obtain an order for a stat
C. Provide the client with extra time for one on one serum lithium level
sessions
D. Allow the client to negotiate the plan of care Answer: (D) Hold the next dose and obtain an order
for a stat serum lithium level
Answer: (A) Agree on a consistent approach among Diarrhea and vomiting are manifestations of Lithium
the staff assigned to the client. toxicity. The next dose of lithium should be withheld
A consistent firm approach is appropriate. This is a and test is done to validate the observation. A. The
therapeutic way of to handle attempts of exploiting manifestations are not due to drug interaction. B.
Cogentin is used to manage the extra pyramidal How can I best help you?”
symptom side effects of antipsychotics. C. The This response reflects the pain due to loss. A helping
common side effects of Lithium are fine hand relationship can be forged by showing empathy and
tremors, nausea, polyuria and polydipsia. concern. A. This is not therapeutic since it passes the
61. Situation: A widow age 28, whose husband died buck or responsibility to the clergy. B. This response
one year ago due to AIDS, has just been told that she is not therapeutic because it gives the client the
has AIDS. impression that she is right which prevents the client
from reconsidering her thoughts. C. This statement
Pamela says to the nurse, “Why me? How could God passes judgment on the client.
do this to me?” This reaction is one of:
A. Depression 63. One morning the nurse sees the client in a
B. Denial depressed mood. The nurse asks her “What are you
C. anger thinking about?” This communication technique is:
D. bargaining A. focusing
B. validating
Answer: (C) anger C. reflecting
Anger is experienced as reality sets in. This may D. giving broad opening
either be directed to God, the deceased or displaced
on others. A. Depression is a painful stage where the Answer: (D) giving broad opening
individual mourns for what was lost. B. Denial is the Broad opening technique allows the client to take
first stage of the grieving process evidenced by the the initiative in introducing the topic. A,B and C are
statement “No, it can’t be true.” The individual does all therapeutic techniques but these are not
not acknowledge that the loss has occurred to exemplified by the nurse’s statement.
protect self from the psychological pain of the loss. 64. The client says to the nurse ” Pray for me” and
D. In bargaining the individual holds out hope for entrusts her wedding ring to the nurse. The nurse
additional alternatives to forestall the loss, knows that this may signal which of the following:
evidenced by the statement “If only…” A. anxiety
62. The nurse’s therapeutic response is: B. suicidal ideation
A. “I will refer you to a clergy who can help you C. Major depression
understand what is happening to you.” D. Hopelessness
B. “ It isn’t fair that an innocent like you will suffer
from AIDS.” Answer: (B) suicidal ideation
C. “That is a negative attitude.” The client’s statement is a verbal cue of suicidal
D. ”It must really be frustrating for you. How can I ideation not anxiety. While suicide is common
best help you?” among clients with major depression, this occurs
when their depression starts to lift. Hopelessness
Answer: (D) ”It must really be frustrating for you. indicates no alternatives available and may lead to
suicide, the statement and non verbal cue of the adolescent establishes his sense of identity by
client indicate suicide. making decisions regarding familial, occupational
65. Which of the following interventions should be and social roles. The adolescent emancipates himself
prioritized in the care of the suicidal client? from the family and decides what career to pursue,
A. Remove all potentially harmful items from the what set of friends to have and what value system to
client’s room. uphold. B. This refers to the middle adulthood stage
B. Allow the client to express feelings of concerned with transmitting his values to the next
hopelessness. generation to ensure his immortality through the
C. Note the client’s capabilities to increase self perpetuation of his culture. C. This reflects school
esteem. age which is concerned with the pursuit of
D. Set a “no suicide” contract with the client. knowledge and skills to deal with the environment
both in the present and in the future. D. The stage of
Answer: (A) Remove all potentially harmful items young adulthood is concerned with development of
from the client’s room. intimate relationship with the opposite sex,
Accessibility of the means of suicide increases the establishment of a safe and congenial family
lethality. Allowing patient to express feelings and environment and building of one’s lifework.
setting a no suicide contract are interventions for 67. The personality type of Ryan is:
suicidal client but blocking the means of suicide is A. conforming
priority. Increasing self esteem is an intervention for B. dependent
depressed clients bur not specifically for suicide. C. perfectionist
66. Situation: A 14 year old male was admitted to a D. masochistic
medical ward due to bronchial asthma after learning
that his mother was leaving soon for U.K. to work as Answer: (B) dependent
nurse. A client with dependent personality is predisposed
to develop asthma. A. The conforming non-assertive
The client has which of the following developmental client is predisposed to develop hypertension
focus: because of the tendency to repress rage. C. The
A. Establishing relationship with the opposite sex perfectionist and compulsive tend to develop
and career planning. migraine. D. The masochistic, self sacrificing type are
B. Parental and societal responsibilities. prone to develop rheumatoid arthritis.
C. Establishing ones sense of competence in school. 68. The nurse ensures a therapeutic environment for
D. Developing initial commitments and collaboration the client. Which of the following best describes a
in work therapeutic milieu?
A. A therapy that rewards adaptive behavior
Answer: (A) Establishing relationship with the B. A cognitive approach to change behavior
opposite sex and career planning. C. A living, learning or working environment.
The client belongs to the adolescent stage. The D. A permissive and congenial environment
 symptoms with the emotional problems can be done
Answer: (C) A living, learning or working when the client is ready.
environment. 70. The client is concerned about his coming
A therapeutic milieu refers to a broad conceptual discharge, manifested by being unusually sad. Which
approach in which all aspects of the environment are is the most therapeutic approach by the nurse?
channeled to provide a therapeutic environment for A. “You are much better than when you were
the client. The six environmental elements include admitted so there’s no reason to worry.”
structure, safety, norms, limit setting, balance and B. “What would you like to do now that you’re about
unit modification. A. Behavioral approach in to go home?”
psychiatric care is based on the premise that C. “You seem to have concerns about going home.”
behavior can be learned or unlearned through the D. “Aren’t you glad that you’re going home soon?”
use of reward and punishment. B. Cognitive
approach to change behavior is done by correcting Answer: (C) “You seem to have concerns about going
distorted perceptions and irrational beliefs to correct home.”
maladaptive behaviors. D. This is not congruent with . This statement reflects how the client feels.
therapeutic milieu. Showing empathy can encourage the client to talk
69. Included as priority of care for the client will be: which is important as an alternative more adaptive
A. Encourage verbalization of concerns instead of way of coping with stressors.. A. Giving false
demonstrating them through the body reassurance is not therapeutic. B. While this
B. Divert attention to ward activities technique explores plans after discharge, it does not
C. Place in semi-fowlers position and render O2 focus on expression of feelings. D. This close ended
inhalation as ordered question does not encourage verbalization of
D. Help her recognize that her physical condition has feelings.
an emotional component 71. Situation: The nurse may encounter clients with
concerns on sexuality.
Answer: (C) Place in semi-fowlers position and
render O2 inhalation as ordered The most basic factor in the intervention with clients
Since psychopysiologic disorder has organic basis, in the area of sexuality is:
priority intervention is directed towards disease- A. Knowledge about sexuality.
specific management. Failure to address the medical B. Experience in dealing with clients with sexual
condition of the client may be a life threat. A and B. problems
The client has physical symptom that is adversely C. Comfort with one’s sexuality
affected by psychological factors. Verbalization of D. Ability to communicate effectively
feelings in a non threatening environment and
involvement in relaxing activities are adaptive way of Answer: (C) Comfort with one’s sexuality
dealing with stressors. However, these are not the The nurse must be accepting, empathetic and non-
priority. D. Helping the client connect the physical judgmental to patients who disclose concerns
regarding sexuality. This can happen only when the return to the unaroused state.
nurse has reconciled and accepted her feelings and 74. The inability to maintain the physiologic
beliefs related to sexuality. A,B and D are important requirements in sexual intercourse is:
considerations but these are not the priority. A. Sexual Desire Disorder
72. Which of the following statements is true for B. Sexual Arousal Disorder
gender identity disorder? C. Orgasm Disorder
A. It is the sexual pleasure derived from inanimate D. Sexual Pain disorder
objects.
B. It is the pleasure derived from being humiliated Answer: (B) Sexual Arousal Disorder
and made to suffer This describes sexual arousal disorder. A. Sexual
C. It is the pleasure of shocking the victim with Desire Disorder refers to the persistent and
exposure of the genitalia recurrent lack of desire or willingness for sexual
D. It is the desire to live or involve in reactions of the intercourse. C. Orgasm Disorder is the inability to
opposite sex complete the sexual response cycle because of the
inability to achieve an orgasm. D. Sexual Pain
Answer: (D) It is the desire to live or involve in Disorder is characterized by genital pain before,
reactions of the opposite sex during or after sexual intercourse.
Gender identity disorder is a strong and persistent 75. The nurse asks a client to roll up his sleeves so
desire to be the other sex. A. This is fetishism. B. This she can take his blood pressure. The client replies “If
refers to masochism. C. This describes exhibitionism. you want I can go naked for you.” The most
73. The sexual response cycle in which the sexual therapeutic response by the nurse is:
interest continues to build: A. “You’re attractive but I’m not interested.”
A. Sexual Desire B. “You wouldn’t be the first that I will see naked.”
B. Sexual arousal C. “I will report you to the guard if you don’t control
C. Orgasm yourself.”
D. Resolution D. “I only need access to your arm. Putting up your
sleeve is fine.”
Answer: (B) Sexual arousal
Sexual arousal or excitement refers to attaining and Answer: (D) “I only need access to your arm. Putting
maintaining the physiologic requirements for sexual up your sleeve is fine.”
intercourse. A. Sexual Desire refers to the ability, The nurse needs to deal with the client with sexually
interest or willingness for sexual stimulation. C. connotative behavior in a casual, matter of fact way.
Orgasm refers to the peak of the sexual response A and B. These responses are not therapeutic
where the female has vaginal contractions for the because they are challenging and rejecting. C.
female and ejaculatory contractions for the male. D. Threatening the client is not therapeutic.
Resolution is the final phase of the sexual response 76. Situation: Knowledge and skills in the care of
in which the organs and the body systems gradually violent clients is vital in the psychiatric unit. A nurse
observes that a client with a potential for violence is applicable. A, B and C are appropriate approaches
agitated, pacing up and down the hallway and during the escalation phase of aggression.
making aggressive remarks. 78. The charge nurse of a psychiatric unit is planning
the client assignment for the day. The most
Which of the following statements is most appropriate staff to be assigned to a client with a
appropriate to make to this patient? potential for violence is which of the following:
A. What is causing you to become agitated? A. A timid nurse
B. You need to stop that behavior now. B. A mature experienced nurse
C. You will need to be restrained if you do not C. an inexperienced nurse
change your behavior. D. a soft spoken nurse
D. You will need to be placed in seclusion.
Answer: (B) A mature experienced nurse
Answer: (A) What is causing you to become The unstable, aggressive client should be assigned to
agitated? the most experienced nurse. A, C and D. A shy,
In a non-violent aggressive behavior, help the client inexperienced, soft spoken nurse may feel
identify the stressor or the true object of hostility. intimidated by the angry patient.
This helps reveal unresolved issues so that they may 79. The nurse exemplifies awareness of the rights of
be confronted. B. Pacing is a tension relieving a client whose anger is escalating by:
measure for an agitated client. C. This is a A. Taking a directive role in verbalizing feelings
threatening statement that can heighten the client’s B. Using an authoritarian, confrontational approach
tension. D. Seclusion is used when less restrictive C. Putting the client in a seclusion room
measures have failed. D. Applying mechanical restraints
77. The nurse closely observes the client who has
been displaying aggressive behavior. The nurse Answer: (A) Taking a directive role in verbalizing
observes that the client’s anger is escalating. Which feelings
approach is least helpful for the client at this time? Taking a directive role in the client’s verbalization of
A. Acknowledge the client’s behavior feelings can deescalate the client’s anger. B. A
B. Maintain a safe distance from the client confrontational approach can be threatening and
C. Assist the client to an area that is quiet adds to the client’s tension. C and D. Use of
D. Initiate confinement measures restraints and isolation may be required if less
restrictive interventions are unsuccessful.
Answer: (D) Initiate confinement measures 80. The client jumps up and throws a chair out of the
The proper procedure for dealing with harmful window. He was restrained after his behavior can no
behavior is to first try to calm patient verbally. . longer be controlled by the staff. Which of these
When verbal and psychopharmacologic documentations indicates the safeguarding of the
interventions are not adequate to handle the patient’s rights?
aggressiveness, seclusion or restraints may be A. There was a doctor’s order for restraints/seclusion
B. The patient’s rights were explained to him. B. Paranoid
C. The staff observed confidentiality C. Histrionic
D. The staff carried out less restrictive measures but D. Antisocial
were unsuccessful.
Answer: (D) Antisocial
Answer: (D) The staff carried out less restrictive These are the characteristics of an individual with
measures but were unsuccessful. antisocial personality. A. Narcissistic personality
This documentation indicates that the client has disorder is characterized by grandiosity and a need
been placed on restraints after the least restrictive for constant admiration from others. B. Individuals
measures failed in containing the client’s violent with paranoid personality demonstrate a pattern of
behavior. distrust and suspiciousness and interprets others
81. Situation: Clients with personality disorders have motives as threatening. C. Individuals with histrionic
difficulties in their social and occupational functions. have excessive emotionality, and attention-seeking
behaviors.
Clients with personality disorder will most likely: 83. The client joins a support group and frequently
A. recover with therapeutic intervention preaches against abuse, is demonstrating the use of:
B. respond to antianxiety medication A. denial
C. manifest enduring patterns of inflexible behaviors B. reaction formation
D. Seek treatment willingly from some personally C. rationalization
distressing symptoms D. projection

Answer: (C) manifest enduring patterns of inflexible Answer: (B) reaction formation
behaviors Reaction formation is the adoption of behavior or
Personality disorders are characterized by inflexible feelings that are exactly opposite of one’s true
traits and characteristics that are lifelong. A and D. emotions. A. Denial is refusal to accept a painful
This disorder is manifested by life-long patterns of reality. C. Rationalization is attempting to justify
behavior. The client with this disorder will not likely one’s behavior by presenting reasons that sounds
present himself for treatment unless something has logical. D. Projection is attributing of one’s behaviors
gone wrong in his life so he may not recover from and feelings to another person.
therapeutic intervention. B. Medications are 84. A teenage girl is diagnosed to have borderline
generally not recommended for personality personality disorder. Which manifestations support
disorders. the diagnosis?
82. A client tends to be insensitive to others, A. Lack of self esteem, strong dependency needs and
engages in abusive behaviors and does not have a impulsive behavior
sense of remorse. Which personality disorder is he B. social withdrawal, inadequacy, sensitivity to
likely to have? rejection and criticism
A. Narcissistic C. Suspicious, hypervigilance and coldness
D. Preoccupation with perfectionism, orderliness and B. Industry vs. inferiority
need for control C. Generativity vs. stagnation
D. Ego integrity vs. despair
Answer: (A) Lack of self esteem, strong dependency
needs and impulsive behavior Answer: (D) Ego integrity vs. despair
These are the characteristics of client with The client belongs to the middle adulthood stage (30
borderline personality. B. This describes the avoidant to 65 yrs.) The developmental task generativity is
personality. C. These are the characteristics of a characterized by concern and care for others. It is a
client with paranoid personality D. This describes the productive and creative stage. (A) Infancy stage (0 –
obsessive compulsive personality 18 mos.) is concerned with gratification of oral needs
85. The plan of care for clients with borderline (B) School Age child (6 – 12 yrs.) is characterized by
personality should include: acquisition of school competencies and social skills
A. Limit setting and flexibility in schedule (C) Late adulthood ( 60 and above) Concerned with
B. Giving medications to prevent acting out reflection on the past and his contributions to others
C. Restricting her from other clients and face the future.
D. Ensuring she adheres to certain restrictions 87. Clients who are suspicious primarily use
projection for which purpose:
Answer: (D) Ensuring she adheres to certain
restrictions A. deny reality
The client is manipulative. The client must be B. to deal with feelings and thoughts that are not
informed about the policies, expectations, rules and acceptable
regulation upon admission. A. Limits should be firmly C. to show resentment towards others
and consistently implemented. Flexibility and D. manipulate others
bargaining are not therapeutic in dealing with a
manipulative client. B. There is no specific Answer: (B) to deal with feelings and thoughts that
medication prescribed for this condition. C. This is are not acceptable
not part of the care plan. Interaction with other Projection is a defense mechanism where one
clients are allowed but the client should be observed attributes ones feelings and inadequacies to others
and given limits in her attempt to manipulate and to reduce anxiety. A. This is not true in all instances
dominate others. of projection C and D. This focuses on the self rather
86. Situation: A 42 year old male client, is admitted than others
in the ward because of bizarre behaviors. He is given 88. The client says “ the NBI is out to get me.” The
a diagnosis of schizophrenia paranoid type. nurse’s best response is:
A. “The NBI is not out to catch you.”
The client should have achieved the developmental B. “I don’t believe that.”
task of: C. “I don’t know anything about that. You are afraid
A. Trust vs. mistrust of being harmed.”
D. “ What made you think of that.” perceived as all good or all bad C.
Counterttransference is a phenomenon where the
Answer: (C) “I don’t know anything about that. You nurse shifts feelings assigned to someone in her past
are afraid of being harmed.” to the patient D. Resistance is the client’s refusal to
This presents reality and acknowledges the clients submit himself to the care of the nurse
feeling A and B. are not therapeutic responses 91. Situation: An 18 year old female was sexually
because these disagree with the client’s false belief attacked while on her way home from work. She is
and makes the client feel challenged D. unnecessary brought to the hospital by her mother.
exploration of the false
89. The client on Haldol has pill rolling tremors and Rape is an example of which type of crisis:
muscle rigidity. He is likely manifesting: A. Situational
A. tardive dyskinesia B. Adventitious
B. Pseudoparkinsonism C. Developmental
C. akinesia D. Internal
D. dystonia
Answer: (B) Adventitious
Answer: (B) Pseudoparkinsonism Adventitious crisis is a crisis involving a traumatic
Pseudoparkinsonism is a side effect of antipsychotic event. It is not part of everyday life. A. Situational
drugs characterized by mask-like facies, pill rolling crisis is from an external source that upset ones
tremors, muscle rigidity A. Tardive dyskinesia is psychological equilibrium C and D. Are the same.
manifested by lip smacking, wormlike movement of They are transitional or developmental periods in life
the tongue C. Akinesia is characterized by feeling of 92. During the initial care of rape victims the
weakness and muscle fatigue D. Dystonia is following are to be considered EXCEPT:
manifested by torticollis and rolling back of the eyes A. Assure privacy.
90. The client is very hostile toward one of the staff B. Touch the client to show acceptance and empathy
for no apparent reason. The client is manifesting: C. Accompany the client in the examination room.
A. Splitting D. Maintain a non-judgmental approach.
B. Transference
C. Countertransference Answer: (B) Touch the client to show acceptance and
D. Resistance empathy
The client finds touch intrusive and therefore should
Answer: (B) Transference be avoided. A. Privacy is one of the rights of a victim
Transference is a positive or negative feeling of rape. C.The client is anxious. Accompanying the
associated with a significant person in the client’s client in a quiet room ensures safety and offers
past that are unconsciously assigned to another A. emotional support. D. Guilt feeling is common
Splitting is a defense mechanism commonly seen in a among rape victims. They should not be blamed.
client with personality disorder in which the world is 93. The nurse acts as a patient advocate when she
does one of the following: Answer: (D) Post traumatic disorder
A. She encourages the client to express her feeling Post traumatic stress disorder is characterized by
regarding her experience. flashback, irritability, difficulty falling asleep and
B. She assesses the client for injuries. concentrating following an extremely traumatic
C. She postpones the physical assessment until the event. This lasts for more that one month A.
client is calm Adjustment disorder is the maladaptive reaction to
D. Explains to the client that her reactions are stressful events characterized by anxiety, depression
normal and work or social impairments. This occurs within 3
months after the event B. Somatoform disorders are
Answer: (C) She postpones the physical assessment anxiety related disorders characterized by presence
until the client is calm of physical symptoms without demonstrable organic
The nurse acts as a patient advocate as she protects basis C. Generalized anxiety disorder is characterized
the client from psychological harm A. The nurse acts by chronic, excessive anxiety for at least 6 months
a a counselor B. The nurse acts as a technician D. 96. Situation: A 29 year old client newly diagnosed
This exemplifies the role of a teacher with breast cancer is pacing, with rapid speech
94. Crisis intervention carried out to the client has headache and inability to focus with what the doctor
this primary goal: was saying.
A. Assist the client to express her feelings
B. Help her identify her resources The nurse assesses the level of anxiety as:
C. Support her adaptive coping skills A. Mild
D. Help her return to her pre-rape level of function B. Moderate
C. Severe
Answer: (D) Help her return to her pre-rape level of D. Panic
function
The goal of crisis intervention to help the client Answer: (C) Severe
return to her level of function prior to the crisis. A,B The client’s manifestations indicate severe anxiety. A
and C are interventions or strategies to attain the Mild anxiety is manifested by slight muscle tension,
goal slight fidgeting, alertness, ability to concentrate and
95. Five months after the incident the client capable of problem solving. B. Moderate muscle
complains of difficulty to concentrate, poor appetite, tension, increased vital signs, periodic slow pacing,
inability to sleep and guilt. She is likely suffering increased rate of speech and difficulty in
from: concentrating are noted in moderate anxiety. D.
A. Adjustment disorder Panic level of anxiety is characterized
B. Somatoform Disorder immobilization, incoherence, feeling of being
C. Generalized Anxiety Disorder overwhelmed and disorganization
D. Post traumatic disorder
97. Anxiety is caused by:
A. an objective threat Antimanic
B. a subjectively perceived threat
C. hostility turned to the self 100. Which of the following is included in the health
D. masked depression teachings among clients receiving Valium?:
A. Avoid foods rich in tyramine.
Answer: (B) a subjectively perceived threat B. Take the medication after meals.
Anxiety is caused by a subjectively perceived threat C. It is safe to stop it anytime after long term use.
A. Fear is caused by an objective threat C. A D. Double up the dose if the client forgets her
depressed client internalizes hostility D. Mania is due medication.
to masked depression
Answer: (B) Take the medication after meals.
98. It would be most helpful for the nurse to deal Antianxiety medications cause G.I. upset so it should
with a client with severe anxiety by: be taken after meals. A. This is specific for
A. Give specific instructions using speak in concise antidepressant MAOI. Taking tyramine rich food can
statements. cause hypertensive crisis. C. Valium causes
B. Ask the client to identify the cause of her anxiety. dependency. In which case, the medication should
C. Explain in detail the plan of care developed be gradually withdrawn to prevent the occurrence of
D. Urge the client to focus on what the nurse is convulsion. D The dose of Valium should not be
saying doubled if the previous dose was not taken. It can
intensify the CNS depressant effects.
Answer: (A) Give specific instructions using speak in
concise statements.
The client has narrowed perceptual field. Lengthy
explanations cannot be followed by the client. B. The
client will not be able to identify the cause of anxiety
C and D. The client has difficulty concentrating and
will not be able to focus.

99. Which of the following medications will likely be

ordered for the client?”
A. Prozac
B. Valium
C. Risperdal
D. Lithium

Answer: (B) Valium

Antianxiety A. Antidepressant C. Antipsychotic D.