The nurse is discussing differentiating psychiatric disorders with a student nurse. Which of the following should be discussed as having a gradual onset and being non-reversible?
Delirium
Dementia
✓
Derealization disorder
Depression
Correct Answer
Dementia
Dementia has a gradual onset and is non-reversible, while delirium has a sudden onset and is usually reversible.
Question 2
The nurse is caring for a client who states that they cannot stop taking their medication because when they do, they feel symptoms such as nausea, vomiting, and pain. What does the nurse anticipate this client is experiencing?
Withdrawal
✓
Dependence
Tolerance
Addiction
Correct Answer
Withdrawal
Withdrawal is a term used to describe the physiological symptoms which occur upon discontinuation of a substance.
Question 3
A nurse is caring for a patient following the sudden death of a spouse. The patient feels paralyzed and cannot cope with work or family responsibilities. Which type of crisis is this patient experiencing?
Situational
✓
Developmental
Maturational
Adventitious
Correct Answer
Situational
Situational crisis refers to loss or change that is often unexpected.
Question 4
The nurse has asked the client to teach back their education on taking an anticholinergic medication. Which of the following interventions stated by the patient requires follow up by the nurse?
Increase fiber intake
Avoid hot environments
Wear sunglasses when outdoors
Decrease fluid intake
✓
Correct Answer
Decrease fluid intake
Patients taking anticholinergic medications should wear sunscreen and sunglasses, avoid excessively hot environments, suck on sugarless candy or chew gum for dry mouth, and increase their fiber and fluid intake to prevent constipation.
Question 5
The nurse is discussing medications that may be used to treat a client experiencing an opiod use disorder with a student nurse. Which medication should be included as an option for long term treatment?
Naloxone
Disulfiram
Acamprosate
Buprenorphine
✓
Correct Answer
Buprenorphine
Buprenorphine is indicated for long term treatment of opioid use disorder. Naloxone is only indicated to reverse acute opioid toxicity. Acamprosate and disulfiram are not indicated in the management of opioid use disorder.
Question 6
The nurse is reviewing labs for a client taking lithum. Which of the following lithium serum levels is considered therapeutic?
1.4 mEq/L
2.0 mEq/L
0.8 mEq/L
✓
0.3 mEq/L
Correct Answer
0.8 mEq/L
The therapeutic range of lithium is 0.6 - 1.2 mEq/L. Levels below 0.6 mEq/L are considered subtherapeutic.
Question 7
The nurse is reviewing labs for a client taking lithum. Which of the following lithium serum levels is indicative of lithium toxicity?
0.7 mEq/L
1.8 mEq/L
✓
1.3 mEq/L
1.0 mEq/L
Correct Answer
1.8 mEq/L
The therapeutic range of lithium is 0.6 - 1.2 mEq/L, however true toxicity does not occur until serum levels are > 1.5 mEq/L
Question 8
A client taking disulfiram chooses to consume alcohol. Which type of behavioral therapy does the reaction mimic?
Aversion therapy
✓
Cognitive behavioral therapy
Dialectical behavioral therapy
Flooding
Correct Answer
Aversion therapy
If a patient drinks alcohol while taking disulfiram, they will become violently ill, mimicking aversion therapy.
Question 9
The nurse is providing education to a child and their parents about a new prescription for methylphenidate. What should the nurse include as something that should be closely monitored?
Height and weight
✓
Cognitive function
Interpersonal behaviors
Liver function
Correct Answer
Height and weight
A child taking methylphenidate should have their height and weight routinely measured as this medication could affect their growth.
Question 10
The nurse is caring for a client taking carbamazepine. Which lab test should the nurse closely monitor?
Troponin
Complete blood count (CBC)
✓
Basic metabolic panel (BMP)
Hepatic function panel
Correct Answer
Complete blood count (CBC)
Carbamazepine is known to cause blood dyscrasias, so a complete blood count is an appropriate lab test to monitor for this complication.
Question 11
The nurse is caring for a client taking valproic acid. The nurse should monitor the function of which organ or system with routine lab testing?
Nervous system
Kidneys
Liver
✓
Spleen
Correct Answer
Liver
Valproic acid is hepatotoxic, so liver function should be closely monitored with routine lab testing.
Question 12
The nurse is educating a client with a new prescription for lithium. The nurse should include in the education that lithim is primarily toxic to which organ?
Spleen
Nerves
Kidneys
✓
Liver
Correct Answer
Kidneys
Lithium is nephrotoxic and can cause damage to the kidneys.
Question 13
The nurse is reviewing anxiolytics with a nursing student. Which class should be discussed as appropriate only for short-term use?
SNRIs
SSRIs
Atypical anxiolytics
Benzodiazepines
✓
Correct Answer
Benzodiazepines
Due to the risk for addiction, benzodiazepines should only be used for the short-term management of anxiety.
Question 14
The nurse is educating a client perscribed an MAOI on the risks of eating food rich in tyramines. What complication should the nurse discuss with the client?
Serotonin syndrome
Hypertensive crisis
✓
Respiratory depression
Hyperemesis
Correct Answer
Hypertensive crisis
Patients taking MAOIs must avoid foods rich in tyramine due to the risk of hypertensive crisis.
Question 15
The nurse is educating a client about anticholinergic side effects of their medication. Which medication is this client most likey perscribed?
Donepezil
Neostigmine
Amitriptyline
✓
Trazodone
Correct Answer
Amitriptyline
Tricyclic antidepressants such as amitriptyline are known for their strong anticholinergic side effects.
Question 16
A patient with a fear of spiders is gradually exposed to photos of spiders, and eventually to a live spider, while engaging in learned relaxation techniques. What is this type of behavioral therapy known as?
Cognitive behavioral therapy
Systematic desensitization
✓
Dialectical behavioral therapy
Flooding
Correct Answer
Systematic desensitization
Systematic desensitization is a type of behavioral therapy where a patient is gradually exposed to a phobia while engaging in learned relaxation techniques.
Question 17
A patient with a fear of elevators is taken to ride an elevator for a prolonged period of time with their therapist until it no longer causes anxiety. What is this type of behavioral therapy known as?
Cognitive behavioral therapy
Dialectical behavioral therapy
Flooding
✓
Systematic desensitization
Correct Answer
Flooding
Flooding is a type of behavioral therapy which exposes the patient to a feared stimuli at full intensity for a prolonged period until it no longer causes anxiety.
Question 18
The nurse is caring for a client who's plan of care includes monitoring for dystonia, akathisia, parkinsonism, and tardive dyskinesia. How would the nurse categorize these symptoms?
Malignant hyperthermia
Serotonin syndrome
Neuroleptic malignant syndrome
Extrapyramidal symptoms
✓
Correct Answer
Extrapyramidal symptoms
Extrapyramidal symptoms is a group of symptoms characterized by dystonia, akathisia, parkinsonism, and tardive dyskinesia.
Question 19
The nurse is caring for a client who is using a device to monitor vital signs with the goal of gaining voluntary control over them. The nurse understands this to be what type of therapy?
Cognitive behavioral therapy
Biofeedback
✓
Dialectical behavioral therapy
ECT
Correct Answer
Biofeedback
Biofeedback is a type of therapy where a device is used to monitor vital signs so that the patient may get feedback on how their emotions affect their vital signs with the goal of obtaining voluntary control over them.
Question 20
A nurse is caring for a patient with ADHD. This patient has been prescribed methylphenidate to decrease impulsivity. For which of the following should the nurse assess?
Weight loss
✓
Drowsiness
Weight gain
Increased appetite
Correct Answer
Weight loss
The nurse should monitor for side effects from methylphenidate such as weight loss, insomnia, and dysrhythmias.
Question 21
A nurse is caring for a patient with schizophrenia. This patient has been prescribed risperidone. Which of the following findings would the nurse understand as a side effect of the medication?
Leukocytosis
Hypercholesterolemia
✓
Hypoglycemia
Weight loss
Correct Answer
Hypercholesterolemia
Agranulocytosis, weight gain, type 2 diabetes, hypercholesterolemia are key side effects of risperidone.
Question 22
A nurse is caring for a client taking lithium. Which of the following symptoms may indicate the client is experiencing lithium toxicity?
Polyuria
Nausea
Coarse tremors
✓
Weight gain
Correct Answer
Coarse tremors
Nausea, polyuria, and weight gain are expected side effects of lithium. Signs of lithium toxicity include course tremors, confusion, hypotension, seizures, and tinnitus.
Question 23
The nurse is developing a plan of care for a client who is participating in group therapy. At what phase does the nurse antipate the client developing a sense of loss and grief?
Working phase
Orientation phase
Collaborative phase
Termination phase
✓
Correct Answer
Termination phase
During the termination phase of group therapy, the patient may feel a legitimate sense of loss or grief.
Question 24
The nurse is reviewing requirements for restraint management with a student nurse. Which of the following statments if made by the student nurse would require follow up?
Assess the patient every 15 minutes
Take vital signs every 2 hours
Provide range of motion exercises every 2 hours
Take off all restraints for 15 minutes every 2 hours
✓
Correct Answer
Take off all restraints for 15 minutes every 2 hours
Restrained patients should be assessed every 15 minutes, and have vital signs, range of motion exercises, fluids, and toileting every 2 hours. Restraints should never be fully removed until there is no longer a need for restraints.
Question 25
The nurse is leading a support group in their community for families affected by suicide loss. Which level of health promotion is this nurse providing?
Quaternary prevention
Tertiary prevention
✓
Secondary prevention
Primary prevention
Correct Answer
Tertiary prevention
Tertiary prevention in mental health focuses on the period after a mental health disorder or crisis has already occurred, and can include support for families affected.
Question 26
The nurse volunteers for a local suicide hotline. Which level of health promotion is this nurse providing?
Secondary prevention
✓
Quaternary prevention
Primary prevention
Tertiary prevention
Correct Answer
Secondary prevention
In mental health, secondary prevention is focused on providing support to those at high risk of experiencing a mental health issue, such as the use of a suicide hotline.
Question 27
A client reports to the nurse that they are experiencing distress about their last child leaving home to go to college. Which type of crisis is this patient likely experiencing?
Situational crisis
Adventitious crisis
Sociocultural crisis
Maturational crisis
✓
Correct Answer
Maturational crisis
Maturational crises occur when a person has difficulty coping with the normal process of development or changes in life, such as a child leaving home.
Question 28
A client has recently had their home being destroyed in a flood. Which type of crisis does the nurse understand this client to be experiencing?
Situational crisis
Maturational crisis
Adventitious crisis
✓
Sociocultural crisis
Correct Answer
Adventitious crisis
An adventitious crisis is one related to rare, unexpected happenings in life, such as natural disaster.
Question 29
The nurse is reviewing nontherapeutic responses when speaking to patients. Which of the following can the nurse include as an example?
Why are you so angry?
✓
Can you tell me more about that?
I hear you saying you're having difficulty focusing.
That sounds like it must be really difficult.
Correct Answer
Why are you so angry?
The nurse should avoid asking "why" questions, as these can appear to be judgmental.
Question 30
The nurse is reviewing levels of anxiety with a student nurse. At which level of anxiety would it still be appropriate to learn something?
Severe
Moderate
Mild
✓
Panic
Correct Answer
Mild
A patient experiencing mild anxiety may still be able to learn.
Question 31
A patient states that after losing his wife three years ago, he has kept her things exactly as they are, and finds it difficult to leave the house or even get out of bed. Which type of grief is the patient experiencing?
Complicated grief
✓
Disenfranchised grief
Anticipatory grief
Normal grief
Correct Answer
Complicated grief
With complicated grief, painful emotions of loss don't improve with time, persist for longer than one year, and are so severe that the patient may have difficulty resuming their normal life.
Question 32
A school nurse is notifiied that a five year old child begins wetting the bed after the arrival of a new baby into the family. Which type of defense mechanism is this child experiencing?
Sublimation
Suppression
Projecting
Regression
✓
Correct Answer
Regression
Regression is a defense mechanism where a person deals with stress by reverting to a previous stage of development, or acting in an age-inappropriate way.
Question 33
A patient tells the nurse that when he gets angry, he takes out that frustration by hitting a punching bag instead of yelling at others. Which type of defense mechanism is this client describing?
Sublimation
✓
Repression
Regression
Displacement
Correct Answer
Sublimation
Sublimation is a defense mechanism in which unacceptable urges are transformed into more productive and acceptable behaviors.
Question 34
The nurse is caring for a client with a history of voluntarily blocking unpleasant feelings. Which defense mechanism does the nurse understand this client to be engaging in?
Repression
Projecting
Suppression
✓
Sublimation
Correct Answer
Suppression
Suppression is the voluntary blocking of unpleasant feelings.
Question 35
When doing an admission assessment, the nurse identifies that the patient's caretaker has failed to provide them with sufficient access to food and medical care. Which type of abuse has the patient experienced?
Financial abuse
False imprisonment
Emotional abuse
Neglect
✓
Correct Answer
Neglect
Neglect is characterized by a caretaker failing to provide for a patient's basic needs, including food and medical care.
Question 36
The nurse is caring for a client who has signed an informed consent. The client tells the nurse they have additional questions about their upcoming procedure. How should the nurse proceed?
Answer the patient's questions
Provide the patient with written educational material
Contact the provider to answer the questions.
✓
Provide the patient with a copy of the informed consent they signed.
Correct Answer
Contact the provider to answer the questions.
The provider is responsible for answering any questions about a procedure, even after informed consent has been obtained.
Question 37
A nurse is caring for a patient on a mental health unit when the patient asks about the medications and their effects. The nurse asks the patient why they need to know this information. Which nontherapeutic communication technique is the nurse demonstrating?
Changing the subject
Behaving Defensively
Asking for an explanation
✓
Arguing
Correct Answer
Asking for an explanation
The use of "why" questions requires the patient provide an explanation that they may not have, causing the patient to become defensive.
Question 38
A nurse is caring for a patient and is in the orientation phase of the nurse-patient relationship. Which of the following communication techniques would be appropriate for the nurse to use during this phase?
Elicit additional information
✓
Talk with interdisciplinary team
Review progress toward personal objectives
Encourage the use self-exploration
Correct Answer
Elicit additional information
Obtaining information from the patient is a component of the orientation phase.
Question 39
The nurse is providing education about schizophrenia to a client and their family. Which of the following should be included as a positive symptom?
Hallucinations
✓
Lack of energy
Anhedonia
Social withdrawal
Correct Answer
Hallucinations
Positive symptoms of schizophrenia are those findings which are not typically present in an average person, such as hallucinations. Negative symptoms are things missing from the patient which are typically seen in an average person such as anergia, anhedonia, and social withdrawal.
Question 40
The nurse is providing education to a client and their family regarding the critera for hospitalization related to the client's anorexia nervosa. Which of the following critera if stated by the family would require follow up by the nurse?
Body fat < 10 %
SBP < 90 mmHg
HR > 100 bpm
✓
Temperature < 96 F
Correct Answer
HR > 100 bpm
Criteria for hospitalization for patients with anorexia nervosa include: electrolyte abnormalities, HR < 50 bpm, SBP < 90 mmHg, arrhythmias, temperature < 96 F, < 75% of ideal body weight, body fat < 10%, and refusal to eat.
Question 41
The nurse is caring for a client with a history of experiencing periods of hypomania and depression. Which diagnosis does the nurse anticipate?
Major depressive disorder
Bipolar I disorder
Borderline personality disorder
Bipolar II disorder
✓
Correct Answer
Bipolar II disorder
Bipolar II disorder is marked by periods of hypomania and depression. Bipolar I disorder is marked by severe mania and depression.
Question 42
The nurse is caring for a client diagnosed with disordered eating. Which of the following interventions would be appropriate to include in the client's plan of care?
Allow the patient to eat in their room
Allow the patient to self-select their meals
Weigh the patient twice per day
Stay with the patient during meals and for at least 1 hour following
✓
Correct Answer
Stay with the patient during meals and for at least 1 hour following
Patients with eating disorders should have supervised meal times and should not be left alone for at least one hour following the meal.
Question 43
The nurse is caring for a client who has had a prolonged history of alcohol abuse. When developing the client's plan of care, the nurse needs to consider that withdrawal symptoms may occur how soon after cessation of alcohol consumption?
1-2 hours
24-48 hours
5-10 hours
✓
5-7 days
Correct Answer
5-10 hours
Following cessation of prolonged alcohol use, withdrawal symptoms may occur within 5-10 hours.
Question 44
The nurse is caring for a client with a history of destruction of property and cruelty to animals. Which mental diagnosis does the nurse anticipate the client has?
Conduct disorder
✓
Borderline personality disorder
Narcissistic personality disorder
Dissociative disorder
Correct Answer
Conduct disorder
Conduct disorder is characterized by theft, destruction of property, and aggression or cruelty to people and/or animals.
Question 45
The nurse is caring for a client and prepares their prescribed dose of donepezil. What diagnosis does the nurse anticipate this client has?
Alzheimer's disease
✓
Obsessive compulsive disorder
Schizophrenia
Parkinson's disease
Correct Answer
Alzheimer's disease
Donepezil is a cholinergic medication often used in the treatment of Alzheimer's disease.
Question 46
The nurse is reviewing personality disorders with a student nurse. Which personality disorder should the student describe as being charachterized by lying, manipulation of others, and violation of social norms?
Dependent personality disorder
Schizotypal personality disorder
Histrionic personality disorder
Antisocial personality disorder
✓
Correct Answer
Antisocial personality disorder
Antisocial personality disorder is characterized by lying, manipulating others, and violating social norms for personal gain.
Question 47
The nurse is caring for a client who expresses having intrusive thoughts and being unable to resist repetitive behaviors. Which mental health disorder does the nurse anticipate as the client's diagnosis?
Cotard syndrome
Bipolar disorder
Obsessive compulsive disorder
✓
Schizophrenia
Correct Answer
Obsessive compulsive disorder
Obsessive compulsive disorder is characterized by intrusive thoughts and the inability to resist repetitive behaviors.
Question 48
The nurse is caring for a client descibing an intense fear of crowds. Which anxiety disorder does the nurse anticipate the client is experiencing?
Agoraphobia
✓
Acrophobia
Arachnophobia
Algophobia
Correct Answer
Agoraphobia
Agoraphobia is the fear of crowds and open spaces.
Question 49
The nurse is providing education to a client and their family about medication for a new diagnosis of ADHD. What time of day should the nurse recommend taking the medication?
Before bed
In the morning
✓
With dinner
After lunch
Correct Answer
In the morning
CNS stimulants used to treat ADHD should be administered in the morning to prevent insomnia.
Question 50
The nurse is caring for a client experiencing hypervigilance, an exaggerated startle response, and detachment from others. What diagnosis does the nurse anticipate this client having?
Generalized anxiety disorder
PTSD
✓
Obsessive compulsive disorder
Major depressive disorder
Correct Answer
PTSD
Patients with PTSD may exhibit hypervigilance, an exaggerated startle response, and detachment from others.
Question 51
A school nurse notes that a child has frequent absences from school, often steals food from other children, and wears clothes that are inappropriate for the weather. Which type of abuse does the nurse suspect the child is experiencing?
Financial abuse
Sexual abuse
Neglect
✓
Emotional abuse
Correct Answer
Neglect
Children who are the victims of neglect may have frequent absences from school, beg or steal food or money, have unclean clothes, body odor or poor hygiene, and wear inappropriate clothes for the weather.
Question 52
A provider gives a verbal order to the nurse to apply non-violent restraints. How soon after this order must the provider perform an in-person assessment of the client?
1 hour
24 hours
✓
12 hours
4 hours
Correct Answer
24 hours
A provider must perform an in-person assessment of the patient within 24 hours of giving an order for non-violent restraints.
Question 53
A client with schizophrenia says to the nurse "I ran to the fan to see the man holding a pan." The nurse understands this client is experncing which type of speech alteration?
Word salad
Flight of ideas
Echolalia
Clang association
✓
Correct Answer
Clang association
Clang association is a speech alteration wherein patients string together rhyming words.
Question 54
The nurse is caring for a client with Alzheimer's disease experiencing agitation, incontinence, and wandering. The nurse understands the client to be in which stage of the disease process?
Preclinical
Stage 2 (Moderate)
✓
Stage 1 (Mild)
Stage 3 (Severe)
Correct Answer
Stage 2 (Moderate)
With moderate Alzheimer's, the patient may exhibit agitation, incontinence, and wandering.
Question 55
A nurse is caring for a patient taking lorazepam. The nurse is assessing the patient and notes respiratory depression. Which medication should be given as an antidote?
Naloxone
Flumazenil
✓
Activated charcoal
Acetylcysteine
Correct Answer
Flumazenil
The antidote for benzodiazepines (e.g., lorazepam) is flumazenil.
Question 56
The nurse is providing education regarding diet to a client taking selegiline. Which of the following would be appropriate for the client to eat?
Avocado
Chocolate
Pepperoni
Oranges
✓
Correct Answer
Oranges
Foods rich in tyramine, such as chocolate, pepperoni, and avocado, must be avoided by patients taking MAOIs such as selegiline. Oranges are okay for this patient to eat.
Question 57
A client with schizophrenia tells the nurse that he is a spy for the CIA. How would the nurse describe this experience?
Delusion
✓
Anhedonia
Command hallucination
Tactile hallucination
Correct Answer
Delusion
Patients with schizophrenia may experience delusions, such as the belief that they are a spy for the CIA.
Question 58
A patient presents to a mental health facility with parotid gland swelling, dental erosion, and Russell's sign. The nurse knows these findings are consistent with which mental health disorder?
Anorexia nervosa
Conduct disorder
Schizophrenia
Bulimia nervosa
✓
Correct Answer
Bulimia nervosa
Bulimia nervosa may be characterized by parotid gland swelling, dental erosion, and Russell's sign.
Question 59
A client with schizophrenia tells the nurse that she hears a voice in her head telling her to run into traffic. The nurse should document that the client is experiencing which symptom?
Echolalia
Delusion
Anergia
Command hallucination
✓
Correct Answer
Command hallucination
Command hallucinations are those wherein a patient hears a voice telling them to do something, such as harming themselves or another person.
Question 60
The nurse is caring for a client experiencing acute alcohol withdrawal. Which medication should the nurse anticipate administering?
Disulfiram
Diazepam
✓
Acamprosate
Naltrexone
Correct Answer
Diazepam
Benzodiazepines such as diazepam may be indicated for patients experiencing acute alcohol withdrawal.
Question 61
The nurse is preparing to educate a client and their family about the risk for detrimental behaviors such as unsafe sexual practices or impulsive spending. For which client diagnosis would this be most appropriate?
Conduct disorder
Bipolar disorder
✓
Major depressive disorder
Schizophrenia
Correct Answer
Bipolar disorder
Patients with bipolar disorder are at risk for detrimental behaviors such as unsafe sexual practices or impulsive spending.
Question 62
The nurse is reviewing signs of anorexia nervosa with a client and their family. Which sign if stated by the family would require follow up?
Amenorrhea
Lanugo
Menorrhagia
✓
Brittle nails
Correct Answer
Menorrhagia
Patients with anorexia nervosa may experience extreme thinness, amenorrhea, lanugo, cold intolerance, brittle hair and nails, constipation, lethargy, and decreased vital signs. Menorrhagia is not commonly associated with anorexia nervosa.
Question 63
While assessing a client's mental status, the nurse notes they are calm and relaxed. Which part of the mental status exam does this fall under?
Thought processing
Speech
Behavior
✓
Mood
Correct Answer
Behavior
Noting the patient is calm and relaxed is part of the behavioral component of the mental status exam.
Question 64
The nurse is reviewing primary characteristics of borderline personality disorder with a new nurse. Which characteristic if stated by the new nurse would require follow up?
Disturbed self image
Echolalia
✓
Intense mood swings
Extreme views
Correct Answer
Echolalia
Patients with borderline personality disorder may experience intense mood swings, impulsivity, extreme views, unstable relationships, disturbed self-image, and a high risk for suicide or self-harm.
Question 65
A patient is yelling at the nurse. The nurse responds, "If you don't stop yelling at me, I'm going to tie you down." Which tort has the nurse committed?
Assault
✓
Negligence
Malpractice
Battery
Correct Answer
Assault
Assault is a threat made against a patient.
Question 66
The nurse teaches a parenting class in the community for first-time parents. Which level of health promotion is the nurse providing?
Secondary prevention
Quaternary prevention
Primary prevention
✓
Tertiary prevention
Correct Answer
Primary prevention
In mental health, primary prevention is focused on increasing patients' exposure to protective factors (e.g., education about birth of a new baby).
Question 67
A nurse accidentally administering the wrong medication to a patient and the patient is harmed. The nurse has commited which tort?
Malpractice
✓
Assault
Battery
Negligence
Correct Answer
Malpractice
Malpractice occurs when a nurse fails to competently perform their medical duties and in so doing, harms the patient.
Question 68
A patient reports that the pain medication they have been taking is no longer working as well as it once did to provide pain relief. The provider decides to increase the medication dose in the hopes that it will relieve their pain again. What does the nurse understand the patient is experiencing?
Tolerance
✓
Dependence
Withdrawal
Addiction
Correct Answer
Tolerance
Tolerance is a term used to describe the phenomenon of a patient having a diminished response to a medication with long-term use.
Question 69
A patient is refusing their medication. The nurse pushes the patient to the ground in order to administer the IM medication. In doing so, the patient to strikes their head and loses consciousness. Which tort has the nurse committed?
Battery
✓
Malpractice
Negligence
Assault
Correct Answer
Battery
Battery is physically touching a patient without their consent and causing harm to that patient.
Question 70
The nurse discusses confidentality and establishes boundaries with a new client. Which phase of the nurse-client relationship is occuring?
The working phase
The termination phase
The orientation phase
✓
The collaborative phase
Correct Answer
The orientation phase
The orientation phase is the point at which a nurse should establish boundaries and discuss confidentiality.
Question 71
A patient states that after yelling at their wife, they try to make things better by bringing her flowers and doing household chores. Which type of defense mechanism does the nurse note this patient exibiting?
Displacement
Undoing
✓
Suppression
Repression
Correct Answer
Undoing
Undoing is the defense mechanism by which one attempts to "cancel out" an unacceptable behavior.
Question 72
A patient reports feeling anxiety accompanied by a sense of doom, hallucinations, trembling, and diaphoresis. Which level of anxiety does the nurse expect this patient experiencing?
Severe
Mild
Moderate
Panic level
✓
Correct Answer
Panic level
Panic level anxiety can be accompanied by hallucinations, delusions, tremors, sweating, and a sense of impending doom.
Question 73
A patient with a terminal diagnosis says to the nurse, "If I can just live long enough to walk my daughter down the aisle, I'll be okay with this." What stage of grief does the nurse expect the patient experiencing?
Depression
Bargaining
✓
Anger
Denial
Correct Answer
Bargaining
In bargaining, the patient attempts to regain some control over their situation by negotiating or even "making a deal" with a higher power.
Question 74
A patient expresses that they do not want to be assigned to a certain nurse because that nurse reminds the patient of their mother. What behavior is the patient exhibiting?
Nonmaleficence
Countertransference
Agitation
Transference
✓
Correct Answer
Transference
Transference is the phenomenon of a patient unconsciously projecting feelings about a person from their past onto someone in the present.
Question 75
The nurse is reviewing how to differentiate overlapping psychatric symptoms with a nursing student. Which of the following is most likely to cause a change in level of consciousness?
Delirium
✓
Derealization disorder
Dementia
Depression
Correct Answer
Delirium
Delirium is marked by a change in level of consciousness.
Question 76
A nurse is caring for a patient with opioid use disorder. The patient has decreased respirations and seems sedated. What should the nurse prepare to administer?
Naltrexone
Naloxone
✓
Flumazenil
Acamprosate
Correct Answer
Naloxone
Naloxone is the antidote for opioid toxicity.
Question 77
A nurse is providing teaching on the symptoms of serotonin syndrome to a client taking an SSRI. Which of the following should the nurse include?
Bradycardia
Diaphoresis
✓
Hypotension
Constricted pupils
Correct Answer
Diaphoresis
Signs and symptoms of serotonin syndrome include agitation, fever, diaphoresis, tremors, tachycardia, nausea, vomiting, and muscle rigidity.
Question 78
A nurse is caring for a patient with a depressive disorder. The patient states, "I just don't feel any happiness or joy in my life anymore." Which of the following terms should the nurse use when documenting this finding?
Anhedonia
✓
Anergia
Anosognosia
Akathisia
Correct Answer
Anhedonia
Anhedonia refers to the patient's inability to experience pleasure or joy.
Question 79
A nurse is providing education to a patient who has newly been perscribed an SSRI. What supplement should the patient be advised to avoid while taking this medication?
Magnesium
Vitamin D
St. John's Wort
✓
Ginseng
Correct Answer
St. John's Wort
St. John's Wort increases the risk of serotonin syndrome and should not be taken with psychiatric medications that increase serotonin levels.
Question 80
A nurse is assessing a newly admitted patient with acute psychosis. The nurse should suspect tardive dyskinesia when the patient begins exhibiting which of the following?
Fine hand tremors and pill rolling
Blurred vision
Tongue thrusting and lip smacking
✓
Sexual dysfunction
Correct Answer
Tongue thrusting and lip smacking
Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as tongue thrusting and lip smacking
Question 81
The nurse administered an incorrect medication to a patient The nurse reasonsed that because the patient did not suffer any adverse reaction, that the nurse did not need to complete an incident report. Which ethical principle did the nurse violate?
Confidentiality
Veracity
✓
Autonomy
Beneficence
Correct Answer
Veracity
Veracity is the duty to tell the truth. The nurse violated the ethical principles of veracity when choosing not to report the error instead of being truthful.
Question 82
A nurse is performing an admission assessment on a patient diagnosed with schizophrenia. Which of the following should the nurse identify as a negative symptom?
Delusions
Flat affect
✓
Hallucinations
Disorganized speech
Correct Answer
Flat affect
Flat affect is a negative symptom of schizophrenia. Remember negative symptoms are something missing from a typical person. Flat affect is lack of expression.
Question 83
A nurse is assessing a patient for the presence of extrapyramidal side effects (EPS). Which of the following findings should the nurse recognize as a sign of EPS?
Urinary retention
Pressured speech
Blurred vision
Tremors of the hands
✓
Correct Answer
Tremors of the hands
Hand tremors are Parkinsonian manifestations which are signs of EPS.
Question 84
The nurse is providing a patient with information about a blood transfusion, including potential risk factors and side effects. Which principle of ethics applies to this nursing action?
Autonomy
Fidelity
Justice
Veracity
✓
Correct Answer
Veracity
This principle of veracity is about telling the truth or being honest. This includes potential risk factors and side effects as it allows the patient to make an informed decision and provide informed consent.
Question 85
The nurse is caring for a patient prescribed amitriptyline. The nurse should monitor the patient for which of the following adverse reactions?
Diarrhea
Metallic taste in mouth
Drooling
Orthostatic hypotension
✓
Correct Answer
Orthostatic hypotension
Orthostatic hypotension is a possible side effect of amitriptyline.
Question 86
A nurse is caring for a patient with suicidal thoughts. What action is most important for the nurse to do?
Assign a private room
Give the patient time to themselves
Place patient in quiet area, away from nurse's station
Implement 1:1 observation
✓
Correct Answer
Implement 1:1 observation
The nurse should implement 1:1 observation, this patient should not be in a private room, they should be close to the nurse's station and checked on frequently.
Question 87
A nurse is educating a patient with depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?
ECT is effective in the treatment of substance use disorder.
A single ECT treatment is typically effective.
Short-term memory loss is the most common side effect.
✓
Medications are given to prevent seizure activity during the procedure.
Correct Answer
Short-term memory loss is the most common side effect.
ECT is use of an electrical current to the brain to create a generalized seizure. It is used for severe depression resistant to antidepressants, schizophrenia, and mania associated with bipolar disorder. 6-12 treatments are typically required. Short term memory loss is the most common side effect of ECT. Memory usually returns within a few weeks.
Question 88
A competent adult patient who was involuntarily admitted to an inpatient mental health facility refuses their medications. What should the nurse do next?
Document the refusal
✓
Administer the medications despite their refusal
Restrain the patient
Contact the provider
Correct Answer
Document the refusal
Despite the involuntary admission, a competent adult patient still has the right to refuse medication.
Question 89
A newly licensed nurse is clarifying how to report suspected child abuse with their nurse preceptor. Which of the following statements indicates an understanding of how to appropriately do this?
"I don't want to defame someone if the report is false."
"If suspicion of abuse exists then reporting is mandatory."
✓
"Evidence must exist prior to reporting."
"If the potential abuser commits to stopping the abuse, I'm not required to report it."
Correct Answer
"If suspicion of abuse exists then reporting is mandatory."
Healthcare workers are legally required to report any suspicions of child abuse even if evidence does not exist.
Question 90
A nurse is educating a patient newly diagnosed with depression about their medication bupropion. Which statement by the patient indicates understanding of the medication teaching?
"I may develop a slow heartbeat while taking bupropion."
"I should expect increased saliva and drooling while taking bupropion."
"I can drink one glass of wine per day while taking bupropion."
"I may not notice a lift in my mood for at least 2 weeks."
✓
Correct Answer
"I may not notice a lift in my mood for at least 2 weeks."
Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). As with other antidepressants, it can take 2-4 weeks for therapeutic effects to occur.
Question 91
The nurse should complete a focused assessment of which body system for a patient who recently took cocaine?
Cardiac
✓
Musculoskeletal
Integumentary
Gastrointestinal
Correct Answer
Cardiac
Patients who recently took cocaine are at risk for tachycardia, hypertension, and sudden cardiac death.
Question 92
A nurse is caring for a patient with ADHD. This patient has been prescribed methylphenidate to decrease impulsiveness. What should the nurse monitor for?
Weight gain
Drowsiness
Weight loss
✓
Increased appetite
Correct Answer
Weight loss
The nurse should monitor for side effects from methylphenidate such as weight loss, insomnia, and dysrhythmias.
Question 93
A nurse is caring for a patient who is experiencing auditory hallucinations. Which of the following should be the nurse's initial response?
"How often do you hear the voices?"
"The voices are part of your illness."
"What are the voices telling you?"
✓
"I know you hear voices, but I do not."
Correct Answer
"What are the voices telling you?"
If the patient is experiencing auditory hallucinations it's important to ask what the voices are saying. Command hallucinations may place the patient or others at risk.
Question 94
The nurse on an inpatient mental health unit is admitting a patient who reports they just lost their job and are feeling hopeless. What should the nurse assess first?
Suicide risk
✓
Psychiatric history
Previous coping skills
Support systems
Correct Answer
Suicide risk
Hopelessness is a sign of impending suicide and the loss of a job puts the patient at higher risk. Therefore, the priority for the nurse to determine is the patient's thoughts or plans for suicide.
Question 95
The nurse is caring for a client scheduled for electroconvlusive therapy (ECT). Which of the following medication orders to be administered during ECT would require immediate follow up?
Neuromuscular blocking agents
Benzodiazepines
✓
Anesthetic agents
Anticholinergics
Correct Answer
Benzodiazepines
Patients undergoing ECT will have an induced seizure, and for this reason no medications should be administered which could prevent seizure, such as benzodiazepines.
Question 96
The nurse is caring for a client with major depressive behavior. Which of the following should be a priorty for the nurse to include in the assessment?
Homicidal ideation
Risky sexual behavior
Suicidal ideation
✓
Flight of ideas
Correct Answer
Suicidal ideation
A patient with major depressive disorder is at high risk for self-harm or suicide.
Question 97
The nurse is caring for a patient with depression and is assessing their ability to perform activities of daily living (ADLs). Prior to discharge, the nurse should identify the patient can perform which of the following activities?
Balancing a Checkbook
Grocery Shopping
Driving
Bathing
✓
Correct Answer
Bathing
The ability to maintain personal hygiene is an essential functional ability included in ADLs.
Question 98
Which of the following patients may provide their informed consent?
An 82 year old with dementia
A 32 year old who has been involuntarily admitted
✓
A 14 year old patient in the emergency room
A 21 year old who has been drinking
Correct Answer
A 32 year old who has been involuntarily admitted
A patient may not provide informed consent if they are < 18 years old, under the influence of drugs or alcohol, or actively experiencing dementia or delirium.
Question 99
A nurse is caring for a patient who is being prescribed lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include when teaching the patient about lithium?
"You will need to stop this medication if you experience vomiting."
✓
"You will need blood levels drawn weekly during the first month of treatment."
"You will need to take this medication on an empty stomach."
"You will need to consume a low-salt diet while on this medication."
Correct Answer
"You will need to stop this medication if you experience vomiting."
Vomiting can lead to dehydration and potentially elevated lithium levels and toxicity. Diarrhea, vomiting, lethargy can also indicate lithium toxicity.