1.
Annie is extremely underweight and disappears into the bathroom after meals, angrily saying to the nurse, “I don’t need to be here. I don’t have any problems. Stop watching me.” To reduce her feeling of being threatened, the nurse would be most therapeutic by responding:
Correct Answer
D. “I hear how frustrated you are to be here.”
Explanation
The correct answer is "I hear how frustrated you are to be here." This response acknowledges Annie's feelings of frustration and validates her emotions. It shows empathy and understanding, which can help to reduce her feeling of being threatened and build a therapeutic relationship between Annie and the nurse.
2.
The nurse recognizes that the most specific signs and symptoms for diagnosing anorexia nervosa are:
Correct Answer
A. Excessive weight loss, amenorrhea, and abdominal distention
Explanation
Excessive weight loss, amenorrhea, and abdominal distention are the most specific signs and symptoms for diagnosing anorexia nervosa. Anorexia nervosa is an eating disorder characterized by a distorted body image and an intense fear of gaining weight, leading to self-imposed starvation and excessive weight loss. Amenorrhea, the absence of menstruation, is common in individuals with anorexia nervosa due to hormonal imbalances caused by malnutrition. Abdominal distention can occur as a result of bloating and constipation, which are common gastrointestinal symptoms in individuals with anorexia nervosa. These specific signs and symptoms help healthcare professionals in diagnosing anorexia nervosa accurately.
3.
Katrina is a 15-year-old client who stands 5-foot, 5-inch-tall, and weighs 80 pounds. She is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes that her problem most likely is caused by:
Correct Answer
D. A desire to control her life
Explanation
Katrina's diagnosis of anorexia nervosa and her extremely low weight for her height suggest that her problem most likely is caused by a desire to control her life. This is a common psychological factor among individuals with anorexia nervosa. Often, the restrictive eating behaviors and obsession with thinness are ways to exert control over their lives in areas they feel they can manage, especially when other parts of their lives feel unpredictable or overwhelming. This need for control is frequently a central issue in anorexia nervosa.
4.
Which characteristic suggests to the nurse that an adolescent may have bulimia?
Correct Answer
A. Frequent bingeing and purging of food
Explanation
The characteristic that suggests to the nurse that an adolescent may have bulimia is frequent bingeing and purging of food. Bulimia nervosa is characterized primarily by episodes of binge eating followed by inappropriate compensatory behaviors such as vomiting (purging), excessive exercise, or use of laxatives. This cycle of bingeing and purging is a key diagnostic feature of bulimia.
5.
Clients with eating disorders often exhibit similar symptoms. The nurse would expect an adolescent client with anorexia to exhibit:
Correct Answer
D. Affective instability
Explanation
The nurse would expect an adolescent client with anorexia to exhibit affective instability. Affective instability refers to rapid and intense shifts in mood, such as going from extreme sadness to anger or irritability. This is a common symptom seen in individuals with eating disorders, particularly anorexia. It is important for the nurse to recognize this symptom as it can impact the client's overall well-being and may require intervention and support.
6.
Mr. Dela Cruz is admitted to the psychiatric unit because of a major depressive disorder. He is exhibiting increasingly withdrawn behaviors. The nurse understands that eventually the client will experience feelings of:
Correct Answer
B. Isolation
Explanation
Given that Mr. Dela Cruz is exhibiting increasingly withdrawn behaviors, it is likely that he will experience feelings of isolation. Isolation is a common symptom of major depressive disorder, where individuals tend to withdraw from social interactions and feel disconnected from others. This feeling of isolation can further worsen the depressive symptoms and hinder the individual's ability to seek support and help.
7.
Which can minimize agitation in a disturbed client?
Correct Answer
A. Limiting unnecessary interactions with the client
Explanation
By limiting unnecessary interactions with the client, it reduces the chances of overstimulation or overwhelming the client, which can further agitate them. This approach allows the client to have a sense of control and autonomy over their environment, which can help minimize agitation and promote a sense of calmness. It also ensures that the client's personal space and boundaries are respected, creating a more comfortable and supportive environment for them.
8.
Aside from feeling sad and having difficulty concentrating and sleeping, what other common signs of depression?
Correct Answer
A. Diminished pleasure in activities and alteration in appetite
Explanation
The common signs of depression, aside from feeling sad and having difficulty concentrating and sleeping, include diminished pleasure in activities and alteration in appetite. Depression often leads to a loss of interest and enjoyment in activities that were previously enjoyable, as well as changes in appetite, such as overeating or loss of appetite. These symptoms are commonly observed in individuals experiencing depression.
9.
Which of the following settings an extremely depressed client can do best?.
Correct Answer
B. Simple daily routines
Explanation
For an extremely depressed client, the best setting would be one that involves simple daily routines. This approach helps by providing structure without overwhelming the client. Simple routines are manageable and predictable, which can reduce stress and the feeling of being overwhelmed, common issues in severe depression. This allows the client to focus on one small task at a time, aiding in gradual improvement in mood and functionality.
10.
The nurse usually has the most difficulty dealing with which type of client with major depression?
Correct Answer
A. Pervasive quality of depression
Explanation
The nurse usually has the most difficulty dealing with clients who have a pervasive quality of depression. This means that the depression is all-encompassing and affects all aspects of the client's life. It can be challenging for the nurse to address and treat this type of depression because it requires a comprehensive approach that targets various areas of the client's functioning. Additionally, the pervasive nature of the depression may make it harder for the client to respond positively to interventions, leading to further difficulties for the nurse in providing effective care.
11.
In caring a depressed client, the nurse should initially:
Correct Answer
D. Accept what the client says
Explanation
Accepting what the client says is important in caring for a depressed client because it helps to establish trust and rapport. It allows the client to feel heard and validated, which can be therapeutic in itself. By accepting what the client says, the nurse creates a safe and non-judgmental environment where the client can freely express their thoughts and feelings. This can also provide valuable insights into the client's experiences and emotions, helping the nurse to better understand and address their needs.
12.
The nurse should include which of the following plan of continuing care for a moderately depressed client?
Correct Answer
B. Offering the client an opportunity to make some decisions
Explanation
The nurse should offer the client an opportunity to make some decisions because it promotes autonomy and empowerment, which can be beneficial for a moderately depressed client. Allowing the client to have a say in their care and activities can help them regain a sense of control and improve their mood. Making all decisions for the client may further contribute to feelings of helplessness and worsen their depression. Encouraging the client to decide how to spend their leisure time can also be a helpful therapeutic intervention in promoting engagement and enjoyment.
13.
Establishing trust is a major nursing goal for a depressed client and can best be accomplished by which of the following nursing considerations?
Correct Answer
A. Spending short periods of time with the client every day
Explanation
Establishing trust with a depressed client is crucial for their well-being and progress. By spending short periods of time with the client every day, the nurse can build a rapport and create a safe and supportive environment. This approach allows the client to gradually open up and feel comfortable sharing their thoughts and feelings. Spending the day with the client might be overwhelming and intrusive, while waiting for the client to initiate conversation or asking them questions daily may create pressure or discomfort. Therefore, spending short periods of time daily is the most effective way to establish trust.
14.
The nurse attends to a depressed client and states, “I will be spending some time with you today. “ The client blurted back irritably by saying, “Go talk to someone else. They need you more.” Which is the nurse’s most therapeutic response?
Correct Answer
A. “I will be spending the next 15 minutes with you.”
Explanation
The nurse's most therapeutic response is "I will be spending the next 15 minutes with you." This response acknowledges the client's irritability and sets a specific time frame for the nurse's presence, which can help the client feel heard and valued. It also shows the nurse's commitment to the client's care and creates a sense of structure and predictability in their interaction.
15.
A client with a diagnosis of acute depression states, “God is punishing me for my past sins.” Which is the nurse’s best response?
Correct Answer
C. “You sound very upset about this.”
Explanation
The nurse's best response is "You sound very upset about this." This response acknowledges and validates the client's feelings without making any assumptions or judgments. It shows empathy and opens up the opportunity for further discussion and exploration of the client's beliefs and emotions.
16.
During the assessment, the nurse should expect which behavior of a client with a diagnosis of schizoid personality disorder?
Correct Answer
B. Detached and socially distant
Explanation
During the assessment, the nurse should expect a client with a diagnosis of schizoid personality disorder to exhibit behavior that is detached and socially distant. Individuals with schizoid personality disorder typically show a lack of interest in social relationships, prefer solitary activities, and display emotional coldness or detachment. This behavior aligns with their characteristic aloofness and limited emotional expression in social settings.
17.
Tristan is a psychiatric client with a diagnosis of histrionic personality disorder. He demands a sleeping pill before going to bed. After being refused, Tristan throws a book at the nurse. The nurse recognizes this behavior as:
Correct Answer
B. Acting out
Explanation
The nurse recognizes Tristan's behavior as acting out. This term is used to describe when an individual expresses their emotions and feelings through actions, often inappropriately, rather than through words. In this context, throwing a book after being refused a sleeping pill is a physical expression of frustration and anger, typical of acting out behaviors, especially in individuals with histrionic personality disorder who may exhibit dramatic, attention-seeking actions.
18.
The desensitization method is utilized successfully by clients experiencing phobias. The method focuses on:
Correct Answer
C. Imagery
Explanation
The desensitization method is a technique used to help clients overcome phobias. It involves gradually exposing the client to the feared object or situation in a controlled and safe manner. Imagery plays a crucial role in this process by allowing the client to visualize the feared object or situation in their mind. By repeatedly imagining the feared stimulus and learning relaxation techniques to counteract anxiety, the client can gradually reduce their fear response. This helps them become desensitized to the phobia and eventually overcome it.
19.
Juan comes to the psychiatric clinic for treatment of phobia about dogs. The nurse at the clinic should anticipate that this client will demonstrate:
Correct Answer
C. Fear of discussing the pHobia
Explanation
Juan's fear of discussing his phobia about dogs suggests that he may have a high level of anxiety or discomfort when it comes to talking about his fear. This fear could stem from a variety of reasons such as embarrassment, shame, or a belief that discussing the phobia will make it more real or intense. It is not uncommon for individuals with phobias to avoid discussing their fears as a way to cope with their anxiety.
20.
A 28-year old female client requested a transfer to another room; she expresses hatred towards her roommate stating she can’t stand to be in the same room with her. Just as she finishes speaking, her roommate enters, she tells her she missed her and has been looking for her all over the unit. The nurse recognizes that the client is using:
Correct Answer
A. Reaction formation
Explanation
The client's behavior of expressing hatred towards her roommate but then immediately acting friendly and expressing love towards her is an example of reaction formation. Reaction formation is a defense mechanism where a person behaves in a way that is opposite to their true feelings or desires. In this case, the client may have negative feelings towards her roommate but is expressing the opposite emotions to hide her true feelings.
21.
Aling Tere, a mother of Anton who is hospitalized for extremely disturbed acting-out behavior, leaves a shopping bag at the desk saying, “This is for my son’s birthday. I’m too busy to visit today.” The gift is an unwrapped expensive pocketbook with the price tags attached. The daughter becomes upset and tearful after being given the message and opening the package. Aling Tere’s action is an example of:
Correct Answer
B. Double-bind message
Explanation
Aling Tere's action of leaving a gift for her son's birthday but not visiting him and leaving the gift unwrapped with price tags attached sends a conflicting and confusing message to her daughter. This creates a double-bind message, where the daughter is caught in a situation where she cannot respond in a way that pleases her mother. The conflicting messages cause emotional distress and upset in the daughter.
22.
A therapeutic relationship has been established by the nurse and acting-out manipulative client in a mental health unit. As the nurse is about to leave, the client says, “Please stay. I’m afraid the evening staff doesn’t like me. They often punish me.” Which is the nurse's response to assist the client?
Correct Answer
A. “You know I leave at this time. We’ll talk about this in the morning.”
Explanation
The nurse's response of "You know I leave at this time. We'll talk about this in the morning" acknowledges the client's fear and offers reassurance that they will address the issue during their next session. This response shows empathy and understanding while also setting appropriate boundaries for the therapeutic relationship. It allows the client to feel heard and understood, while also maintaining the structure and consistency of the nurse's role.
23.
Rosalinda is diagnosed with borderline personality disorder and has been demonstrating manipulative, inappropriate behavior, and consistently attempting to the advantage of the other clients. Before confronting the client, which should be the nurse first to consider?
Correct Answer
C. Depth of their working relationship
Explanation
The nurse should first consider the depth of their working relationship before confronting Rosalinda about her behavior. This is important because a strong working relationship built on trust and understanding will provide a better foundation for addressing the issue effectively. By assessing the depth of their relationship, the nurse can determine if they have established enough rapport with Rosalinda to have an open and honest conversation about her manipulative behavior. This approach will increase the likelihood of a positive outcome and minimize potential harm to the therapeutic alliance.
24.
Following a conference with a psychiatrist, a client with borderline personality disorder cries bitterly, pound the bed in frustration, and threatens suicide. It would be most helpful for the nurse to:
Correct Answer
A. Sit down and listen attentively if the client wishes to talk about the problem.
Explanation
For a client with borderline personality disorder who is displaying intense emotions and making threats of suicide, it is important for the nurse to provide a supportive and empathetic environment. Sitting down and attentively listening to the client if they wish to talk about their problem allows the nurse to establish a therapeutic relationship and provide a safe space for the client to express their emotions. This approach shows respect, validation, and understanding towards the client's feelings, which can help in de-escalating the situation and promoting a sense of trust.
25.
The nurse is aware that the withdrawn pattern of behavior eventually produces feelings of:
Correct Answer
A. Loneliness
Explanation
The nurse understands that when someone exhibits a withdrawn pattern of behavior, it can lead to feelings of loneliness. When a person withdraws from social interactions and isolates themselves, they may feel disconnected from others and experience a sense of loneliness. This can be a result of not having meaningful connections or support from others, which can contribute to feelings of sadness and isolation.