CARE FOR CLIENTS WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS

SITUATION 1: Technique of therapeutic communication should be utilized and

incorporated into nursing practice.

1. When a nurse establishes a therapeutic relationship with a client, which of the

following is the primary focus of the client’s care?
a. The medical diagnosis c. The nursing diagnosis
b. The client’s needs and problems d. The client’s social interaction

2. Which of the following is the overall purpose of therapeutic communication?

a. To analyze client’s problems
b. To elicit cooperation
c. To facilitate a helping relationship
d. To provide emotional support

3. In which of the following situations would communications be LEAST likely

hindered?
a. Mrs.L, 30 years old is admitted to the hospital for the first time for acute
appendicitis
b. Mrs. R, 50 years old, diabetic, is admitted to the hospital after a stroke. She has
right hemiplegia
c. Mrs. D, 45 years old, is admitted to the hospital for cervical cancer
d. Mr. T, 70 years old, is admitted for fractured tibia. He speaks Spanish only

4. Which of the following communication technique is MOST effective in dealing

with covert communication?
a. Listening c. Clarification
b. Evaluation d. Validation

5. Which of the following is MOST important in fostering a positive

relationship?
a. The nurse recognizes that some patient regress when confronted with illness
b. The nurse functions as a positive role model to encourage health oriented patient
behavior
c. Needs to understand that patients may test her before he can accept
and trust her
d. The nurse must fully share the patient’s feelings before she can develop her goal
for her nursing care
SITUATION 2: Stress can bring about various human reactions that may result to
illness or enhance one’s coping mechanism. Stress also triggers local and general
adaptation syndrome.

6. Which of the following BEST describes the general adaptation syndrome. It

is a:
a. Psychological response to stress c. Behavioral response to stress
b. Physiologic response to stress d. Sociocultural response to stress

7. Which of the following levels of anxiety is BEST for client’s learning?

a. Moderate c. Severe
b. Mild d. No anxiety

8. Which of the following defense mechanism is consciously used in coping

mechanism with stress?
a. Regression c. Repression
b. Suppression d. Projection

9. Which of the following models identifies ability to cope with stress, practice and
norms of the peer group, effect of social environment and the resources used to
deal with stress as determinants to stress and stress reactions?
a. Stimulus based model c. Response based model
b. Adaptation based model d. Transaction based model

10. The purpose of the first stage of the General Adaptation Syndrome is which
of the following?
a. Determine the causes of the danger
b. Present the individual from having an unpleasant experience
c. Mobilize energy needed for adaptation
d. Alert the individual to danger

SITUATION 3: Paul, 16 year old was committed to a mental health facility with
diagnosis of personality disorder. He has a history of promiscuity and running away.
He tells the staff “I can’t stand this place, I want to go away.”

11. How would the nurse deal effectively with Paul’s threat to run away?
a. Tell him to stay in her room
b. Lock him in her room
c. Tell him firmly that if he does not control herself, the staff will help him control
herself
d. Ignore the threat

12. The early experiences of Paul may indicate a history of:

a. Severe parental rejection c. Severe temper tantrums
b. Failure in interpersonal relationship d. Failure to identify positively with father

13. How would you describe parental rejection?

a. Failure to identify positively with father c. Lack of recognition as a person
b. Lack of parental love and discipline d. Lack of the capacity to trust others

14. What should the nurse do to prevent Paul from manipulating and dominating
others?
a. Ignore him demands c. Observe him closely
b. Isolate Paul d. Protect others from being manipulated
Answer: D- Safety precautions must be posed to protect others, provide
endorsement to other nurses

15. In dealing with manipulative behavior, the nurse should convey an attitude of:
a. Active friendliness c. Love and understanding
b. Permissiveness d. Consistency
Answer: D- Firmness, matter of fact and consistency is used to approach clients with
antisocial personality

SITUATION 4: Mark was brought to the National Center for Mental Health for
substance abuse.

16. Which of the following behaviors would indicate stimulant intoxication?

a. Slurred speech, unsteady gait, impaired concentration
b. Hyperactivity, talkativeness, euphoria
c. Relaxed inhibitions, increased appetite, distorted perceptions
d. Depersonalization, dilated pupils, visual hallucinations

17. Which of the following statements would indicate the teaching about Naltrexone
(Revia) had been effective?
a. “I’ll get sick if I use heroine on this medication.”
b. “This medication will block the effects of any opioid substance I take.”
c. “If I use opioid while taking naltrexone, I’ll become extremely ill.”
d. “Using naltrexone may make me dizzy.”

18. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of

the following nursing assessments is essential before giving a dose of this
medication?
a. Assessing the client’s blood pressure
b. Determining when the client last use an opiate
c. Monitoring the client for tremors
d. Completing a thorough physical assessment

19. The nurse has provided an in-service program on impaired professionals. She
knows that teaching has been effective when staff identify the following as the
greatest risk for substance abuse among professionals:
a. Most nurses are codependent in their personal and professional relationships
b. Most nurses come from dysfunctional families and are risk for developing
addiction
c. Most nurses are exposed to various substances and believe they are not risk to
develop the disease
d. Most nurses have preconceived ideas about what kind of people become addicted

20. The client tells the nurse that she takes a drink every morning to calm her
nerves and stops her tremors. The nurse realizes the client is at risk for:
a. An anxiety disorder c. Physical dependence
b. A neurological disorder d. Psychological addiction

SITUATION 5: A nurse must be aware of the latest issues on Child Abuse and Family
Violence.

21. Marinel, a 16 years old young lady was left with her stepfather and with a
mother who is working in the office the whole day. As a nurse, what would be your
advice?
a. Tell the mother to keep watching her daughter
b. Tell the child get to her regular activities
c. Ask the child to get away from her stepfather
d. Let the child stay with the relatives

22. Marinel’s high school friend made a visit and talked to her father. Marinel feels
fidgety and continuously smoked while her friend is talking to her mother. Beth is
experiencing:
a. Worries
b. Anger
c. Nervousness
d. Stress

23. The best way a nurse can advise an abused child is to call the:
a. Police station
b. School
c. Parish
d. Bantay Bata 163

24. When planning the care for a client who is abused, which of the following
measures would be most important to include?
a. Being compassionate and empathetic
b. Teaching the client about abuse and the cycle of violence
c. Explaining to the client his or her personal and legal rights
d. Helping the client develop a safety plan

25. During the session with the nurse, a client who is being abused states, “I don’t
know what to do anymore. He doesn’t want me to go anywhere while he’s at work,
not even to visit my friends.” Which of the following nursing diagnoses would the
nurse formulate in respect to this information?
a. Risk for violence related to abusive husband, as evidenced by victim’s statement
of being battered
b. Low Self-Esteem related to victimization, as evidenced by not being able to leave
the house
c. Powerlessness related to abusive husband, as evidenced by inability to make
decisions
d. Ineffective Coping related to victimization, as evidenced by crying
SITUATION 6: The following questions pertains to Musculoskeletal System of aging
persons

26. Which of the following behaviors contribute to osteoporosis:

a. Smoking, and lack of exercise c. Drinking tea, deep breathing, and losing weight
b. Physical activity, dancing, and swimming d. Knee bends, shopping, and weight
lifting

27. As people gets older, they lose height (become shorter). This is due to:
a. The fact that they don’t stand up straight c. Loss of bone mass in the vertebral
discs
b. The rest of the population has grown taller d. Inaccurate measurement

28. As one ages, muscle mass (that is muscle size):

a. Decreases c. Stays about the same
b. Increases d. Can go either way

29. As a result of changes in long bones and the spinal column, the gait of older
people:
a. Becomes like a dancer c. Is more steady
b. Is less stable and balanced when walking d. Hardly changes at all

30. Changes in the bone of older people make which of the following a major
danger?
a. Infection c. Allergy
b. Contagion d. Fractures

SITUATION 7: Sensory deprivation is experienced by most people in any setting

whether they are patients confined in hospitals, workers assigned in mining
industries or a family member assigned in far places.

31. Which of the following will LEAST likely result to sensory deprivation?
a. Increased sensory input brought about by unlimited visitors from families and
friends
b. Restriction of the environment in patients who are on absolute bed rest
c. Reduced sensory input in the case of patients who have just been operated on
glaucoma
d. Elimination of order or “meaning” from input in the case of ICU patients or was in
reverse isolation

32. Which of the following are observed in sensorially deprived adult and elderly
people because of deafness?
a. They prefer interaction with hearing adults
b. They show greater interdependence than hearing adult
c. They become more flexible in daily routine
d. They show poor social judgment

33. Which nursing intervention would be appropriate for client with hyperthesia?
a. Firm pressure when touching body parts c. Minimal use of direct touch
b. Vigorous hair brushing d. Frequent back rubs

34. A post-operative blind patient needs to be assisted for ambulation. Which of the
following should the nurse do in ambulating a client with visual impairment?
a. Stand on the client’s nondominant side, approximately one step behind the
client, grasping the client’s arm
b. Stand on the client’s dominant side and grasp the client’s arm
c. Stand on the client’s dominant aside slightly in front of the client, allowing the
client to grasp the nurse’s arm
d. Stand slightly in front of the client’s nondominant side allowing the client to grasp
the nurse’s arm

35. Which of the following is an appropriate communication method for client’s with
hearing impairment?
a. Talk side by side with the client
b. Use visual aide and gestures to enhance the spoken word
c. Restrict use of the client’s hands
d. Speak loud enough or shout if you may so that client will be able to hear you

SITUATION 8: Sexuality is one problem area that is often neglected by nurses in the
care of elderly clients. The nurse however must be able to identify and address the
sexual changes to provide nursing care.

36. Menopause is considered complete when:

a. Hot flashes cease c. A woman has been without periods for a year
b. Emotional stability ends d. Irritability goes away

37. Hormonal decline in women causes:

a. Increased risk for atherosclerotic plaques c. No changes in risk for atherosclerotic
plaques
b. Decreased risk for atherosclerotic plaques d. None of the above

38. Benefits of hormone replacement therapy (HRT) include:

a. Protection against constipation
b. Protection against osteoporosis and elimination of the unpleasant symptoms of
menopause
c. Protection against the flu
d. Protection against fever

39. Which of the following is NOT a known risk of hormone replacement therapy:
a. Formation of blood clots and hypertension
b. Development of noncancerous fibroid tumors in the uterus
c. Breast and endometrial cancers
d. Lung cancer

SITUATION 9: The nurse is caring for an adult admitted with a diagnosis of brain
tumor. He was scheduled for craniotomy.

40. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of
the cerebral cortex. Post operatively, the position that would be most appropriate
for this client would be:
a. High fowler’s with knee gatch raised
b. Flat with small pillow under the nape of the neck
c. Head of the bed elevated 20 degrees with the head turned to the operative side
d. Head of the bed elevated 45 degrees with a large pillow under the head and
shoulders

41. A client is regaining consciousness after a craniotomy becomes restless and

attempts to pull out her intravenous line. Which nursing intervention protects the
client without increasing her ICP?
a. Place her in a jacket restraint
b. Wrap her hands in soft “mitten” restraints
c. Tuck her arms and hands under the draw sheet
d. Apply a wrist restraint to each arm

42. Following 3 months of rehabilitation after craniotomy, a female client is still

having some motor speech difficulty. To promote the client’s use of speech the
nurse should:
a. Correct her mistakes immediately
b. Respond to her crude efforts of speaking
c. Re-explain why she is having difficulty of speaking
d. Speak to her in simple words and short sentences

43. A client undergoes a craniotomy for removal of her brain tumor. The nurse notes
that her dressing is saturated with blood. Which of the following interventions is
most appropriate?
a. Replacing the dressing
b. Marking the area of drainage on the dressing
c. Reinforcing the dressing and notifying the doctor immediately
d. Doing nothing because this is normal occurrence

44. After craniotomy, what is your primary goal?

a. Prevent increased ICP
b. Prevent infection
c. Prevent secondary surgery
d. Prevent hemorrhage

SITUATION 10: Dementing illness and changes in the brain

45. As one gets older, there is a loss of brain cells. The significance of this is:
a. A cell transplant is indicated
b. The lost cells will regenerate on their own
c. The remaining cells are more than enough for learning and remembering
d. The significance is not known

46. ACUTE dementia is due to causes which can be reversed. A frequent cause of
this type of dementia is:
a. Cerebrovascular accident
b. Alzheimer’s disease
c. Multiple Infarcts
d. Electrolyte imbalance, especially hyponatremia (loss of sodium)

47. When assessing a client with dementia, which of the following behaviors would
the nurse interpret as a manifestation of disinhibition?
a. Wandering and getting lost
b. Auditory and/or visual hallucinations
c. Decreased interest in bathing and hygiene
d. Inappropriate language and sexual behaviors

48. The brains of persons with Alzheimer’s disease are characterized by the
presence of:
a. Fatty deposits c. Calcium deposits
b. Senile plaques and neurofibrillary tangles d. Lack of gray matter
SITUATION 11: A 23 year-old man was voluntarily admitted to the inpatient unit with
a diagnosis of paranoid schizophrenia.

49. As the nurse approaches the client, he says, “If you come any closer, I’ll die.”
This is an example of:
a. Hallucination
b. Delusion
c. Illusion
d. Idea of reference

50. Delusion is:

a. Psychomotor disturbance
b. Mood disturbance
c. Disturbance of thought
d. Disturbance of perception

51. When communicating with a paranoid client, the main principle is to:
a. Use logic and be persistent
b. Provide an anxiety-free environment
c. Express doubt and do not argue
d. Encourage ventilation of anger

52. The client tells his primary nurse that he’s scheduled to meet the President of
the Philippines a special time, making it impossible for the client to leave his room
for dinner. Which of the following responses by the nurse is most appropriate?
a. “It’s meal time. Let’s go so you can eat.”
b. “The President of the Philippines told me to take you to dinner.”
c. “Your physician expects you to follow the unit’s schedule.”
d. “People who don’t eat on this unit aren’t being cooperative.”

53. A schizophrenic patient who began taking haloperidol (Haloperidol) 1 week ago
now exhibits jerking movements of the neck and mouth. These are signs of:
a. Dystonia
b. Psychosis
c. Akathisia
d. Parkinsonism

SITUATION 12: Nico, 27 yrs. old, is admitted for treatment of a major depression.
54. He is withdrawn, appears disheveled, and states, “No one could ever love me.”
The nurse can expect the client to be placed on
a. Antiparkinsonism medication
b. Suicide precautions
c. A low-salt diet
d. Phototherapy

55. Which of the following behaviors indicates to the nurse that a client’s major
depression is improving? The client:
a. Displays a blunted effect
b. Has lost an additional 2 pounds
c. States one “good” thing about himself
d. Sleeps about 16 hours per day

56. Nico is scheduled for electroconvulsive therapy (ECT) tomorrow. The nurse
would plan for which of the following activities?
a. Force fluids 6 to 8 hours before treatment
b. Administer succinylcholine (Inestine, Anectine) during pretreatment care
c. Encourage the client’s spouse to accompany him
d. Reorient the client frequently during posttreatment care

57. Nico is recovering from a severe depression. Which of the following behaviors
alerts the nurse to a risk for suicide?
a. The client sleeps most of the day
b. The client has a plan to kill himself
c. The client loses 5 pounds
d. The client does not attend unit activities

58. Nico has been depressed severely depressed for 2 weeks. He had mentioned
“ending it all” prior to admission. Which of the following questions should the nurse
ask during the prescreen assessment?
a. “How long have you thought about harming yourself?”
b. “What is it that makes you think about harming yourself?”
c. “How has your concentration been?”
d. “What specifically have you thought about doing to harm yourself?”

SITUATION 13: A client is admitted with a diagnosis of Alzheimer’s Disease.

59. When developing the plan of care for a client with Alzheimer’s disease who is
experiencing moderate impairment, which of the following types of care would the
nurse expect to include?
a. Considerable assistance with activities of daily living
b. Managing complex medication schedule
c. Constant supervision and total care
d. Supervision of risky activities, such as shaving

60. Which of the following would be priority to include in the plan of care for a client
with Alzheimer’s disease who is experiencing difficulty processing and completing
complex tasks?
a. Repeating the directions until the client follows them
b. Asking the client to do one step of the task at a time
c. Demonstrating for the client how to do the task
d. Maintaining routine and structure for the client

61. Clients with Alzheimer’s disease may have delusions about being harmed by
staff and others. When the client expresses fear of being killed by staff, which of the
following responses would be most appropriate?
a. “What makes you think we want to kill you?”
b. “We like you too much to want to kill you.”
c. “You are in the hospital. We are nurses trying to help you.”
d. “Oh, don’t be so silly. No one wants to kill you here.”

62. When helping the families of clients with Alzheimer’s disease to cope with
vulgar or sexual behaviors, which of the following suggestions would be most
helpful?
a. Ignore the behaviors, but try to identify the purposes
b. Give feedback on the inappropriateness of the behaviors
c. Employ anger management strategies
d. Administer the prescribed risperidone (Risperdal)

63. The nurse determines that the son of the client with Alzheimer’s disease needs
further education about the disease when he makes which of the following
statements?
a. “I didn’t realize the deterioration would be so incapacitating.”
b. “The Alzheimer’s support group has so much good information.”
c. “I get tired of the same old stories, but I know it’s important for Dad.”
d. “I woke up this morning hoping that my old Dad would be back.”
SITUATION 14: A 34-year old is hospitalized with bipolar disorder.

64. The nurse knows that the major factor that distinguishes a bipolar from a
unipolar disorder is the
a. Higher incidence in women
b. Severity of the depression
c. Genetic etiology
d. Presence of mania

65. At 2 a.m. the nurse the nurse finds him phoning friends all across the country to
discuss his new plan for eradicating world hunger. His excited explanations are
keeping the entire unit awake, but he won’t quiet down. The nurse caring for him
knows the drug most likely to be prescribed for this client is:
a. A tricyclic depressant
b. An MAOI-inhibitor antidepressant
c. Lithium carbonate (Eskalith)
d. An antianxiety drug

66. Supportive therapy for a client who is exhibiting manic behavior may include all
of the following EXCEPT:
a. Psychoanalysis
b. Cognitive therapy
c. Interpersonal therapy
d. Problem-solving therapy

67. The client is creating considerable chaos in a day treatment program with
dominating and manipulative behavior. Which of the following nursing intervention
is most appropriate?
a. Allow the peer group to intervene
b. Describe acceptable behavior and set realistic limits with the client
c. Recommend the client to be hospitalized for treatment
d. Tell client that his behavior is not appropriate

68. The client is skipping up and down the hallway practically running into other
clients. Which of the following activities would the nurse expect to include in the
client’s plan of care?
a. Leading a group activity
b. Watching television
c. Reading the newspaper
d. Cleaning the dayroom tables

SITUATION 15: A client is admitted to outpatient surgery for cataract extraction on

the right eye.

69. The client asks, “What does the lens of my eye do?” The nurse should explain
that the lens of the eye:
a. Produces aqueous humor
b. Holds the rods and cones
c. Focuses light rays onto the retina
d. Regulates the amount of light entering the eye

70. The client would most likely to complain of which symptoms?

a. Halos and rainbows around lights
b. Eye pain and irritation that worsens at night
c. Blurred and hazy vision
d. Eye strain and headache when doing close work

71. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine)

into a client’s right eye before cataract removal surgery. This preparation acts in
the eye produce
a. Dilatation of the pupil and blood vessels
b. Dilatation of the pupil and constriction of blood vessels
c. Constriction of the pupil and constriction of blood vessels
d. Constriction of the pupil and dilatation of blood

72. A short time after cataract surgery, the client complains of nausea. Which of the
following represents the nurse’s best course of action?
a. Instruct the client to take a few deep breaths until the nausea subsides
b. Explain that this is a common feeling that will pass quickly
c. Tell the client to call the nurse promptly if vomiting occurs
d. Medicate the client with an antiemetic, as ordered
73. Discharge planning would include:
a. Wearing eye patches for the first 72 hours
b. Lifting light objects is acceptable
c. Bending with the knees and keep the head straight
d. Bending with the waist is acceptable if slowly done

SITUATION 16: A client is admitted with a diagnosis of Parkinson’s disease.

74. Which of the following is an initial sign of Parkinson’s disease?
a. Rigidity
b. Tremor
c. Bradykinesia
d. Akinesia

75. The nurse develops a teaching plan for a client newly diagnosed with
Parkinson’s disease. Which of the following topics that the nurse plans to discuss is
the most important?
a. Maintaining a balanced nutritional diet
b. Enhancing the immune system
c. Maintaining a safe environment
d. Engaging in diversional activity

76. When does the nurse encourage a client with Parkinson’s disease to schedule
the most demanding physical activities to minimize the effects of hypokinesia?
a. Early in the morning, when the client’s energy level is high
b. To coincide with the peak action of drug therapy
c. Immediately after a rest period
d. When family members will be available

77. Which goal is the most realistic and appropriate for a client diagnosed with
Parkinson’s disease?
a. To cure the disease
b. To stop the progression of the disease
c. To begin preparations for terminal care
d. To maintain optimal body function

78. The client needs a long time to complete her morning hygiene, but she becomes
annoyed when the nurse offers assistance and refuses all help. Which statement is
the nurse’s best initial response in this situation?
a. Tell the client firmly that she needs assistance and help her with her care
b. Praise the client for her desire to be independent and give her extra time and
encouragement
c. Tell the client that she is being unrealistic about her abilities and accept that she
needs help
d. Suggest to the client that if she insists on self care, she should at least modify her
routine
SITUATION 17: A client is admitted to the hospital with Bell’s Palsy.

79. A client with Bell’s Palsy asks the nurse why artificial tears were ordered by the
physician. Select the best reply by the nurse.
a. “When your affected eye fails to make tears, the eye can become irritated and
ulcerated.”
b. “ Because your eye remains closed, foreign matter can be trapped beneath the
lid.”
c. “Artificial tears will remove the purulent drainage from your eye, which speeds
healing.”
d. “Because you cannot blink the affected eye, it can become dry and irritated.”

80. Which nursing diagnosis takes priority for the patient with Bell’s palsy?
a. Risk for dysfunctional grieving
b. Risk for injury related to corneal laceration
c. Risk for chronic low self-esteem
d. Risk for impaired physical mobility

81. The nurse observes that the client’s right eye does not close completely. Based
on this, which of the following nursing interventions would be most appropriate?
a. Making sure the client wears her eyeglasses at all times
b. Placing an eye patch over her eye
c. Instilling artificial tears once every shift
d. Cleansing the eye with a clean washcloth every shift

82. The client has a feeling of stiffness and a drawing sensation of the face. What
would be an important teaching to the patient?
a. Eye is susceptible to injury when eyelid does not close
b. Drooling from an increased saliva on the affected area may occur
c. Cleaning the eye will prevent ulceration
d. All of the above

SITUATION 18: A 46-year old is admitted to the hospital because her family is
unable to manage her constant hand washing rituals.

83. Her family reports she washes her hands at least 30 times each day. The nurse
noticed the client’s hands are reddened, scaly, and cracked. The main nursing goal
is to:
a. Remind the client several times of her appointment
b. Limit the number of hand washings
c. Tell her it is her responsibility to be there on time
d. Provide ample time for her to complete her rituals

84. Which of the following is an appropriate treatment for this client?

a. An unstructured schedule of activities
b. A structured schedule of activities
c. Intense counseling
d. Negative reinforcement every time she performs her rituals

85. The most effective way for the nurse to intervene with her hand and face
washing is to:
a. Allow her a certain amount of time each shift to engage in this behavior
b. Interrupt the activity briefly and frequently
c. Lock the door to her room and restrict access to the bathroom
d. Tell her to stop each time she is observed doing it

86. The client is also constipated and dehydrated. Which nursing intervention would
the client be most likely to comply with?
a. Drinking Ensure between meals
b. Drinking extra fluids with meals
c. Drinking 8 oz water every hour between meals
d. Drinking adequate amounts of fluid during the day

87. Upon admission she was also dehydrated and underweight. The nurse and the
client will know
That discharge planning is appropriate when the client:
a. Regains her normal body weight
b. Expresses a desire to leave the hospital
c. Is able to start talking about her guilt and anxiety
d. Limits her hand and face washing to a few times a day

SITUATION 19: The nurse is caring for a client who is experiencing panic attack.

88. Which intervention would be most appropriate?

a. Tell the client he’s all right, and there is no need to panic
b. Speak to the client in short, simple sentences
c. Explain to the client that there’s no need to worry because he’s safe
d. Give the client a detailed explanation of his panic reaction

89. The client reports that she often feels a choking sensation in her throat, a racing
heart, dizziness and fearfulness. All of these symptoms have occurred almost daily
for the past 3 months. Suspecting a psychological component to these symptoms,
what would the nurse anticipate administering?
a. Benzodiazepines
b. Proton pump inhibitors
c. Nitropusside
d. Lithium carbonate

90. The client has a generalized anxiety disorder. Which statement is true about this
client?
a. The client has regular obsessions
b. Relaxation techniques and psychotherapy are necessary for care
c. Nightmares and flashbacks are common in individuals who suffer from
generalized anxiety disorder
d. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6
months

91. The client is pacing and complains of racing thoughts. The nurse asks the client
if something upsetting happens, and the client response is vague and not focused
on nurse’s question. The nurse assesses the client’s level of anxiety as:
a. Mild
b. Moderate
c. Severe
d. Panic

92. Which of the following is a behavior manifestation of anxiety, except:

a. Panic
b. Tachycardia
c. Hyperventilation
d. Tachypnea

SITUATION 20: Defense Mechanisms

93. Sam is diagnosed with cancer does not talk about or acknowledge the diagnosis.
Which of the following defense mechanism is Sam using?
a. Denial
b. Identification
c. Projection
d. Rationalization

94. Nathaniel, released from prison for selling narcotics has been rehabilitated and
now works for a youth drug prevention agency. Darwin is reflecting which of the
following defense mechanism?
a. Denial
b. Displacement
c. Identification
d. Sublimation

95. Nina is admitted to the ICU with chest pain, an abnormal ECG, and elevated
enzymes. When the significance of this is explained to her, she says, “I can’t be
having a heart attack. No way. You must be mistaken.” The nurse suspects the
client is using which defense mechanism?
a. Sublimation
b. Regression
c. Dissociation
d. Denial
96. In patients with dissociative disorders, the defense mechanism most often used
to block traumatic experiences is:
a. Passive-aggression
b. Reaction formation
c. Denial
d. Repression

97. The defense mechanism utilized by manic patients to cover up depression is:
a. Displacement
b. Denial
c. Compensation
d. Reaction formation

SITUATION 21: Psychosomatic disorders

98. A man’s family brought him onto the hospital because of his many somatic
complaints. He has been seen by many medical specialists in the past without
discovery of organic pathology. The nurse assesses that the client is probably
experiencing which of the following problems?
a. Conversion disorder
b. Body dysmorphic disorder
c. Malingering
d. Hypochondriasis

99. Amie is hospitalized for treatment of conversion disorder. She complained of

paralysis of her right side after her husband threatened to leave her and their
children. She seems unconcerned about her paralysis. An appropriate long term
goal for the nurse to formulate is that client will:
a. Cope effectively with stress without using conversion
b. Identify stressors
c. Express feelings about conflict
d. Develop an increased sense of relatedness to others

100. A patient who reports paralysis with no specific cause but has a history of a
recent stressful event has a probable diagnosis of:
a. Hypochondriasis
b. Somatic illness
c. Conversion disorder
d. Pain disorder