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    Exam Review

    1. A nurse is collecting data from a client who has schizophrenia. Which of the following client findings should the nurse document as a positive symptom of the disorder?
      A)Dysphoria
      B)Poor hygiene
      C)Disorganized speech
      D)Anhedonia
    2. A nurse is caring for a client who states, "I am not going to take my medication anymore." Which of the following responses should the nurse make?
      A)"Why don't you want to take the medication?"
      B)"You won't get better unless you take the medication."
      C)"Tell me more about this decision."
      D)"I always do what the doctor tells me to do."
    3. A nurse is caring for a client diagnosed with antisocial personality disorder who frequently violates unit rules and manipulates others to avoid consequences. Which nursing intervention is most appropriate to manage this behavior?
      A)Set clear, consistent limits with defined consequences.
      B)Allow the client some flexibility with rules to promote trust.
      C)Provide the client with increased privileges immediately when they demonstrate good behavior.
      D)Encourage the client to express feelings of guilt during group therapy.
    4. Which of the following questions should the nurse ask to assess intimate partner safety?(SATA)
      A)Do you ever feel pressured to do something that you did not want to do or felt uncomfortable doing?
      B)Are you afraid of anyone with whom you have had a previous relationship?
      C)Do you feel safe in your relationship?
      D)Has your caretaker hurt you or threatened to harm you?
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    Exam Review

    1. A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
      A)Sleeping 12 hr or more each day
      B)Constant need to talk about the event
      C)Increasing feelings of anger
      D)Increasing sense of attachment to others
    2. A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?
      A)I have heard that abusers try to keep their partner isolated from others.
      B)I know that abusers lack social supports and social skills.
      C)I have heard that abusers think of themselves as important and have high self-esteem.
      D)I know that men who are abusers gain power through intimidation.
    3. A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority?
      A)Protecting the client from self-harm behavior
      B)Providing strategies for redirecting violent behavior
      C)Encouraging the client to talk about her feelings
      D)Exploring reasons for her behavior
    4. A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?
      A)The client has full range of motion in her wrist.
      B)The client is attempting to remove the restraint.
      C)The client's hand is cool and pale.
      D)The client has a capillary refill of 1 second.
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    Exam Review

    1. A nurse is caring for a child who reports being abused by a family member. Which of the following statements should the nurse make?
      A)"I promise I won't tell anyone about this."
      B)"Your family is bad for doing this to you."
      C)"It is not your fault that this happened."
      D)"Let's discuss what you have told me with your family members."
    2. A nurse is caring for a client who has schizophrenia and notices changes in the client's behavior. Which of the following behaviors is the nurse's priority to report to the provider?
      A)Eating half of meals
      B)Diminished facial affect
      C)Decreased energy level
      D)Bizarre behaviors
    3. A nurse is collecting data for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse should recognize this finding as which of the following?
      A)Automatic obedience
      B)Gustatory hallucination
      C)Negativism
      D)Command hallucination
    4. A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?
      A)Clang associations
      B)Flight of ideas
      C)Confabulation
      D)Grandiosity
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    Exam Review

    1. A nurse is assisting in the care of a client who has schizophrenia and is experiencing a hallucination. Which of the following actions by the nurse is appropriate?
      A)Instruct the client to argue with the voices that are a part of the hallucination.
      B)Tell the client that the hallucination is not a part of reality.
      C)Act like the hallucination is real.
      D)Ask the client direct questions about the hallucination.
    2. A nurse is interviewing a client who has borderline personality disorder. The nurse and client have agreed on an interview time, but the client resists discussing her feelings until 5 min prior to the end of the session and then asks for additional time. Which of the following actions should the nurse take?
      A)Set an extra meeting time to discuss the client's feelings.
      B)End at the scheduled time, telling the client that she can continue at the next scheduled session.
      C)Arrange for another nurse to continue the interview.
      D)Extend the scheduled time, as the client is finally able to discuss important feelings.
    3. A nurse is talking to a client who is explaining about her home situation and the intimate partner violence she recently experienced. Which of the following responses should the nurse make?
      A)"Let's talk about what is going on at work."
      B)"Now that you have come for help, you will feel much better."
      C)"I'd like to hear more about how you are feeling."
      D)"Why do you think your partner is angry with you?"
    4. A nurse is collecting data from a client who is receiving multiple antipsychotic medications. The client exhibits muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should identify that the client may be experiencing which of the following adverse effects?
      A)Neuroleptic malignant syndrome
      B)Acute dystonia
      C)Tardive dyskinesia
      D)Pseudoparkinsonism
    Page 4 of 5

    Exam Review

    1. A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
      A)The client talks constantly about the traumatic experience.
      B)The client is constantly drowsy and sleeps 11-12 hr daily.
      C)The client reports satisfying personal relationships with family and close friends.
      D)The client is easily startled by loud voices.
    2. A nurse in a community clinic is caring for a client whose partner was just killed by a drunk driver. The client states, "I have no idea how I even got here. I cannot think right now." Which of the following actions should the nurse take first?
      A)Assist the client in prioritizing decisions that must be made.
      B)Determine whether the client is at risk for self-harm.
      C)Help the client to identify personal strengths he can use in a crisis situation.
      D)Identify a support person to notify and to take the client home.
    3. A nurse is caring for a client who was admitted to an acute care mental health facility for treatment of borderline personality disorder. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?
      A)Ask the client if she has a plan to commit suicide.
      B)Recognize the attempt at manipulation and escort the client back to her activity.
      C)Assist the client to her room and allow her to rest before resuming activity.
      D)Notify the client’s family and request a visitor to stay with the client until thoughts of suicide are gone.
    4. A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?
      A)Display disapproval toward the perpetrator.
      B)Probe the client to offer a factual account of the abuse.
      C)Invite a family member to be present for the nursing history.
      D)Be direct and honest when communicating with the client.
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