1.
Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
Correct Answer
B. Tolerance
Explanation
tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.
2.
Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disordersThe client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
Correct Answer
A. Delirium tremens
Explanation
Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.
3.
Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. The care for the client places priority to which of the following:
Correct Answer
A. Monitoring his vital signs every hour
Explanation
Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.
4.
Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
Correct Answer
B. Cocaine
Explanation
The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations.
5.
Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders.A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
Correct Answer
B. Narcan (Naloxone)
Explanation
Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine
6.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
Correct Answer
C. Agnosia
Explanation
This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.
7.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
Correct Answer
C. “This must be difficult for you and your mother.”
Explanation
This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.
8.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
Correct Answer
C. Remains in a safe and secure environment
Explanation
Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently
9.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
Correct Answer
A. “Your husband is dead. Let me serve you your breakfast.”
Explanation
The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation
10.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.Dementia unlike delirium is characterized by:
Correct Answer
B. Insidious onset
Explanation
Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.
11.
Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?
Correct Answer
B. Fluid volume deficit
Explanation
Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.
12.
What is the best intervention to teach the client when she feels the need to starve?
Correct Answer
C. Approach the nurse and talk out her feelings
Explanation
he client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.
13.
The client with anorexia nervosa is improving if:
Correct Answer
B. Weight gain
Explanation
Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.
14.
The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
Correct Answer
A. Have episodic binge eating and purging
Explanation
Bulimia is characterized by binge eating which is 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. Low esteem is noted in both eating disorders
15.
A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
Correct Answer
A. Patient will learn problem solving skills
Explanation
if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.
16.
N the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
Correct Answer
B. Discuss their eating behavior.
Explanation
The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
17.
Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies The client is suffering from:
Correct Answer
C. ClaustropHobia
Explanation
Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.
18.
Initial intervention for the client should be to:
Correct Answer
D. Accept her fears without criticizing.
Explanation
The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.
19.
The nurse develops a countertransference reaction. This is evidenced by:
Correct Answer
A. Revealing personal information to the client
Explanation
A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past.
20.
Which is the desired outcome in conducting desensitization:
Correct Answer
D. The client will be able to overcome his disabling fear.
Explanation
The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.
21.
Which of the following should be included in the health teachings among clients receiving Valium:
Correct Answer
A. Avoid taking CNS depressant like alcohol.
Explanation
Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.
22.
Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?
Correct Answer
C. The conversion symptom has symbolic meaning to the client
Explanation
the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.
23.
Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
Correct Answer
D. “How do you feel about being pressured into sex by your boyfriend?”
Explanation
Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.
24.
Malingering is different from somatoform disorder because the former:
Correct Answer
B. It is a deliberate effort to handle upsetting events
Explanation
Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.
25.
Unlike psychophysiologic disorder Linda may be best managed with:
Correct Answer
C. Stress management techniques
Explanation
Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.