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NURSING PRACTICE V
ASSESSMENT EXAM
Situation: The occurrence of degenerative changes and impaired sensorineural function (hearing,
vision) disorders may affect client’s work, lifestyle and activities of daily living.
1. An old male client, 63 years old has hearing loss and ear pain is being diagnosed with labyrinthitis.
What condition is the most likely cause?
A. Recent history of Ménière's disease
B. Recent history of mumps
C. Recent history of sinusitis
D. Recent history of tympanosclerosis
Correct Answer: B
Labyrinthitis is an infection of the inner ear that can be caused by a virus or bacteria. It is associated with
recent respiratory tract infections, measles, mumps, or rubella. Ménière's disease is mostly characterized
by vertigo. There is no recent notation of trauma to the tympanic membrane.
REFERENCE: Medical – Surgical Nursing by: Joyce Black
2. After conducting assessment the nurse prepares to irrigate the client's left ear to remove a foreign
body. The nurse wants to prevent the client from becoming dizzy during the procedure. Which
intervention is most likely to assist in reaching this goal?
A. Having the client sit with his left ear toward the nurse
B. Using water that is warmed to body temperature
C. Using saline that is at room temperature
D. Having the client sit with the left ear up to hold the fluid in
Correct Answer: B
Irrigating with fluid that is either warmer than or cooler than body temperature sets the client up for
dizziness. It is best to use water and not saline, and the ear that will be irrigated should be pointed toward
the nurse.
3. The novice nurse is attending to a male client with a history of hearing and speech impairment since
he was 4 years old. The nurse has attempted several times to provide instructions to him on how to
use the call light system. At present both the client and the nurse are frustrated. The nurse wants to
know why the client is unable to comprehend the instruction. How should the nurse respond?
A. "The client has been hearing impaired since a very young age when language is being learned,
so the client experiences confusion."
B. "Reading lips is the client’s preferred method of communication so you need to slow your
speech."
C. "The client prefers sign language; speech reading is difficult, as many of the sounds
produced require rapid movement of the mouth and the client must guess at the words
spoken."
D. "Is this a change in behavior? Let me provide the instruction and I will complete an assessment;
maybe there is something going on."
Correct Answer: C
Speech reading (lip reading) is at times difficult to use as a method of communication because many of the
words in our language are not easily produced without sound and, therefore, the client using speech
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reading has trouble and needs to guess at many of the words. This is frustrating to the client as well as the
health care worker. But just the knowledge of the difficulties the client faces should make the
communication a little easier and the nursing assistant should have more patience.
4. Another client is admitted to the emergency department for complaints of headaches, otalgia, and
sudden loss of hearing in the left ear. What should the nurse expect the physician to order?
A. Corticosteroid
B. Antihistamine
C. Antibiotics
D. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct Answer: A
Because the hearing loss is sudden, the nurse would expect the physician to order corticosteroids to
determine whether some of the hearing loss can be reversed. Antibiotics would be administered if the
hearing issues were related to an infection. The antibiotics then could also assist in preventing further
hearing loss. The hearing loss is not an allergic reaction, so an antihistamine would not be beneficial.
5. A postoperative client has undergone an Ossiculoplasty. What nursing diagnosis is of priority?

A. Impaired Sensory Hearing
B. Pain
C. Risk for Injury: Falls
D. Risk for Hemorrhage
Correct Answer: C
Due to the manipulation of the inner ear, clients may be at risk for falling after this surgical procedure. The
manipulation causes vertigo or lightheadedness, especially when the client is getting up for the first time.
Hearing is hopefully improved after the surgery. Pain is not usually an issue and can be medicated. The
risk of hemorrhage is small.
Situation: Liza an Emergency room nurse has just undergone a post-training course with
specialization in sensory-neurologic conditions. She is preparing the patients for interview and
assessment.
6. Franco a male client at 56-year-old is complaining of blurred vision, sometimes double vision, light
sensitivity, and excessive glare. He has been diagnosed with cataracts and is awaiting surgery. What
interventions should Liza teach the client to aid in increasing his vision until surgery can be
arranged?
A. Wear wrap-around sunglasses with dark lens.
B. Restrict driving to daylight hours.
C. Take two Tylenol for the pain.
D. Avoid lifting anything heavier than 5 pounds.
Correct Answer: A
Blurred vision, sometimes monocular diplopia (double vision), photophobia (light sensitivity), and glare
occur because the opacity of the lens obstructs the reception of light and images by the retina. Clients
usually see better in low light, when the pupil is dilated, which allows for vision around a central opacity.
There is no complaint of pain.
A wrap-around dark lens might add to the client's vision during the day, assisting the client and improving
quality of life. Driving restrictions are not apparent, and the client has no pain, so taking Tylenol is not
necessary. Avoiding heavy lifting is a restriction for after the surgery.
7. Another young male client in his early 20s, a construction worker was brought to the emergency
department with the complaint of severe pain in the right eye. The right eye was profusely tearing,
red, and swollen. The physician removed a very small piece of wood from the right eye and applied a
patch. Liza prepared his discharge instructions. What statement by the client validates the need for
additional instruction?
A. "I have called by roommate and he will be here shortly to drive me home."
B. "When I get home, it is OK to remove the patch as long as I do not read."
C. "I need to continue to put the eye drops in my eye as prescribed."
D. "I need to stay home from work until the physician states otherwise."
Correct Answer: B
After a corneal injury, the client must rest the eye, which includes not reading but also includes keeping the
eye closed. Because the client has one eye patched, his depth perception is affected, so it is safest to have
another individual drive the client home. More than likely there will be antibiotic eye drops that will need to
be instilled on a schedule and these drops will need to be instilled per the physician's orders. Activity
restrictions are at the physician's discretion.
8. A client Robert is brought to the emergency department by a family member with a complaint of
change of vision. Upon questioning, the nurse notes that the vision changes were sudden, appearing
as black spots in the area closest to the nose. The physician looks into the eye and states that the
retina has areas that appear bluish gray. Nurse Liza suspects which of the following?
A. Cataracts
B. Glaucoma
C. Detached retina
D. Corneal injury
Correct Answer: C
Areas of detachment appear bluish gray as opposed to the normal red-pink color. Cataracts, glaucoma,
and corneal injury do not manifest these symptoms.
9. Robert is admitted with a newly diagnosed detached retina. Nurse Liza should place highest priority
on doing which of the following?
A. Limiting visitors and providing clear liquids
B. Allowing client to get out of bed but keeping room darkened
C. Giving eye drops every hour and allowing bathroom privileges only
D. Placing client on bedrest and patching the eyes
Answer: D. (pg. 633) The client with a detached retina should have activity restricted (option A) with eyes
patched to reduce eye movement and prevent worsening of the detachment (option D). The client may be
prepared for surgery quickly, and thus may be placed on NPO status rather than clear liquids (option A).
Eye drops are not necessary (option C).
Reference: Medical-Surgical Nursing by Mary Ann Hogan

10. When planning care for a client who is legally blind, you should do which of the following as most
important to ensure the client’s safety?
A. Leave doors partially closed
B. Orient client verbally and physically to the room
C. Provide radio and television for stimulation
D. Describe the whether and community events for client
Answer: B. (pg. 633) The nurse should orient the client to the room for safety, using both words and a
physical walking tour for best effect (option B). Options C and D are helpful, but do not ensure client safety.
Leaving doors partially closed (option A) is hazardous because the client could inadvertently walk into the
door during ambulation. Pathways should be free of obstacles.
Reference: Medical-Surgical Nursing by Mary Ann Hogan
Situation: In a Rehabilitation facility medical and nursing interventions were immediately

implemented to prevent further complications.
11. Following a stroke, a client is transferred to a rehabilitation facility. Which action will the admitting
nurse take first?
A. Perform a multidimensional assessment of the client.
B. Explain the plan of care to the client and family.
C. Introduce the members of the rehabilitation team.
D. Discuss the length of time available for rehabilitation.
ANSWER: A - The first action by the nurse will be to perform an assessment of the client. The plan of care,
members needed for the client's rehabilitation team, and length of time for rehabilitation cannot be
determined until the assessment is completed.
12. A nurse is reviewing orders for a client diagnosed with brain attack who is being admitted to a
rehabilitation nursing unit. The physician has ordered vital signs and neurological assessment every
4 hours for 48 hours, physical therapy, occupational therapy, and speech therapy to evaluate and
treat. What additional orders should the nurse expect?
A. D5 1/2 NS with 20 mEq KCL@100 mL/hr
B. Fiber, stool softener, and PRN laxative
C. Bed rest, with client out of bed only with therapy
D. Intermittent catheterization every 4 hours
Correct Answer: B
The client will not be as mobile as before the stroke, so the possibility of the client becoming constipated is
increased. Straining to have a bowel movement increases the intracranial pressure so the client will be on a
bowel regimen to prevent straining. The intravenous fluids provide additional fluids, and therapy will
determine the client's ability to get up into a chair to ambulate. Intermittent catheterization is not completed
every 4 hours due to the risk of introducing microorganisms into the urinary tract.
13. Within the first 72 hours for clients with diagnosis of stroke, which of the following interventions will
assist in preventing complications?
A. Discontinue the indwelling catheter to reduce risk of infection.
B. Encourage fluids, at least eight 8-ounce glasses of water.
C. Monitor neurological status every 4 hours with vital signs.
D. Cluster the nursing care together to avoid increasing intracranial pressure (ICP).
Correct Answer: C
Monitoring the neurological status every 4 hours provides the nurse and the health care team with
important information as to how the client is internally managing the stroke. Clustering care will increase the
ICP and therefore care is spaced accordingly. At this early of a time, the client may not be cleared to drink
water because the client would need to have had a speech therapy consult and a modified barium swallow.
Even though discontinuing the catheter may prevent infection, an infection is not the main concern of the
health care team at this stage of recovery.
14. A staff nurse is developing a teaching plan on stroke prevention. Which item should be identified as a
priority?
A. "Wear a medical alert bracelet if you have atrial fibrillation."
B. "'Clot busters' must be given within 3 hours of symptoms."
C. "Have family transport to the emergency department."
D. "If symptoms occur, wait 30 minutes then call 911."
Correct Answer: B
Clients with ischemic stroke who are eligible for thrombolytic therapy should be reviewed immediately for
candidacy and then once confirmed should receive medication within 3 hours of the onset of the symptoms.
It is important for the client to wear a medical alert bracelet identifying the atrial fibrillation but this is not the
most important message to take home from the program. It is better for an individual with a suspected
stroke to be transported to the hospital under the care of a life squad, and if someone suspects symptoms
of a stroke, do not wait to call for help. The priority point here is knowing that there is a time limit on the
"clot busting" drugs.
15. Which action by the Rehabilitation nurse will be most effective in ensuring that a client who has had
severe burn injuries will be successfully discharged home?
A. Administer all ordered medications and treatments on time.
B. Make referrals to community resources that can assist the family.
C. Provide written instructions about management of potential problems.
D. Assure the client and family that they have the skills to provide home care.
ANSWER: B - Because the ability of caregivers to provide home care is the most important factor in
determining whether a client is able to be discharged home, interventions that provide support for the family
are the most important nursing actions in achieving this goal. The other actions will also be implemented by
the nurse, but they will not be as helpful in ensuring that the client will be successfully discharged home.
Situation: Nurse Fely chose to be assigned in a Rehabilitation facility despite the risk involve and
special nursing care required to clients with complicated conditions.
16. Fely admitted a 70-year-old client to an acute Rehabilitation facility, which information is most
important for nurse Fely to obtain regarding the client?
A. Medical diagnoses
B. Functional abilities
C. Communication skills
D. Health history
ANSWER: B - Because the major goal of rehabilitation is to improve client function, a baseline assessment
of functional abilities is essential. In addition, the admission form for Medicare-approved acute rehabilitation
requires assessment of functional abilities. The other information is also important, but assessment of client
functioning is the priority.
17. When educating clients and family members on the rehabilitation unit, which nursing action is most
likely to result in retention of the information?
A. Emphasize the importance of the information to the client’s long-term health.
B. Use standardized materials to avoid omission of essential information.
C. Determine what the client and family believe are the most important teaching needs.
D. Choose the highest priority topics based on the client’s medical diagnosis.
ANSWER: C - Because the client is at the center of the rehabilitation process, and research suggests that
rehabilitation clients retain information best when they feel it is relevant, the most effective approach starts
with determining the education priorities of the client and family. The other approaches are less likely to be
effective in ensuring retention of new information.
18. Which information obtained by the nurse about a client who is in a rehabilitation facility after having a
hip fracture is most likely to determine whether the client will be able to be discharged home?
A. The client has a history of emphysema.
B. The client wants to be discharged home.
C. The client has 8 out of 10 hip pain when ambulating.
D. The client’s family is able to help with home care.
ANSWER: D - Research indicates that the most important factor determining whether a client will be
discharged into the community is the availability of informal caregivers such as family members. The other
factors will impact rehabilitation, but they are not as significant as the family's ability to assist with care after
discharge.
19. A nurse manager of the hospital is planning a new rehabilitation unit for clients who have had acute
head injuries, which type of team approach will be optimal?
A. Multidisciplinary
B. Interdisciplinary
C. Intradisciplinary
D. Transdisciplinary
ANSWER: D - A transdisciplinary approach, in which multiple team members provide input to a primary
therapist who works with the client, is best for clients with cognitive disorders, such as clients with acute
head injuries. An intradisciplinary team approach is not described in the text. Multidisciplinary and
interdisciplinary team approaches may be used in rehabilitation, but they are not the optimum approaches
for clients with head injuries because the client is likely to be confused by interactions with multiple team
members.
20. The spouse of a client who is preparing to return home after rehabilitation for a spinal cord injury tells
the nurse, "I just feel too overwhelmed by the idea of this discharge. I don't think that it's the right
time yet." Which nursing diagnosis is appropriate to add to the plan of care?
A. Ineffective Denial related to lack of acceptance of the client’s injury
B. Interrupted Family Processes related to client’s absence from the home
C. Risk for Caregiver Role Strain related to spouse’s anxiety about discharge
D. Ineffective Therapeutic Regimen Management related to insufficient education
ANSWER: C - The spouse's statements indicate that caregiver role strain is a potential problem because of
the spouse's anxiety about being able to care for this client. Information about community resources and
referrals for home health visits, for example, are appropriate interventions for this client and spouse. There
is no evidence to support Ineffective Denial, Interrupted Family Processes, or Ineffective Therapeutic
Management as nursing diagnoses for this client (although these are potential diagnoses for clients
needing rehabilitation).
Situation: A client with Osteoarthritis is conversing with the nurse regarding appropriate measures
to improve joint mobility and muscle strengthening.
21. Which activity suggested by client Nelson demonstrates the he needs for additional understanding on
how to promote mobility and strength?
A. Swimming
B. Walking
C. Jogging
D. Aerobics
Correct Answer: A
Weight-bearing exercise leads to increased joint mobility and strengthens the joint's supporting muscles,
tendons, and ligaments. Swimming is not a weight-bearing exercise.
22. Nelson has been diagnosed with osteoarthritis (OA) of the knee and has received instruction on how
to manage the condition. Which of the following statements demonstrates a need for additional
instruction?
A. "I need to find a local tai chi class to improve my strength."
B. "I can use heat or cold to reduce the pain in my knee."
C. "I should take Advil instead of Tylenol to relieve the pain."
D. "I can use a cane for a short time when my knee flares up."
Correct Answer: C
Because OA only has a minor inflammatory component, nonsteroidal anti-inflammatory drugs (NSAIDs)
may not be the best first-line choice. Furthermore, research suggests that NSAIDs disrupt cartilage
metabolism and individuals who take NSAIDs could suffer from gastrointestinal bleeding. Tylenol is the
drug of choice because of its effectiveness, safety, and low cost. Tylenol is less likely to produce
gastrointestinal, liver, or kidney damage. Practicing tai chi helps improve flexibility and that will help with
muscle strength. Either hot or cold applications will assist in reducing pain, as will resting the joint by using
a cane.
23. An older client has a history of Osteoarthritis (OA) and was recently treated for increased stiffness in
his hands. In the effort to preserve self-care, what intervention would the nurse suggest to the client?
A. Using very big buttons that do not require fine motor movements
B. Using Velcro as a fastener instead of small buttons
C. Using open-healed slippers instead of shoes for easy access
D. Using a long-handled toothbrush when cleaning the teeth
Correct Answer: B
Self-fastening tape or Velcro assists the client in maintaining independence with dressing and hygiene. No
matter what the size of the button is, some fine motor movement is required for maneuvering a button
through a buttonhole. Open-healed slippers pose a safety risk and a long-handled toothbrush would not be
beneficial; however, a thick-handled toothbrush would allow the client to manage cleaning the teeth.
24. A nurse is developing an educational program on the prevention of Osteoporosis. Which of the
following age groups would be the best target audience?
A. Adults younger than 20 years old
B. Adults between 21 and 30 years old
C. Adults between 31 and 40 years old
D. Adults between 41 and 50 years old
Correct Answer: A
Strong adult skeletons are built during childhood. Peak bone mass is usually attained by age 30, yet bone
loss in the hip probably starts as early as age 20. Peak bone mass as well as later bone loss is a major
determinant of osteoporotic fractures.
25. A 20-year-old client is seen in the Physician's office for routine physical. While discussing the client's
history, the nurse notes that the client has an aunt who has osteoporosis and had recently suffered a
vertebral fracture. The nurse provides the client with additional information on Osteoporosis and
calcium intake. What action by the client would suggest the need for additional education?
A. She will increase the calcium in her diet because she drinks coffee all day long.
B. She will spend at least 15 minutes in the sun with sunscreen on.
C. She will decrease the amount of sodium she uses at meal times every day.
D. She will add walking to her weekly exercise plan of swimming and biking.
Correct Answer: B
Although the use of sunscreen is important to reduce photo aging and the risk of skin cancer, when
sunscreen is applied, the skin receives no sunlight and vitamin D is not synthesized in the skin. Caffeine
and sodium both cause the body to excrete calcium in the urine; therefore either a reduction in caffeine and
sodium consumption is necessary or supplements should be added. Walking is a weight-bearing exercise
that helps build and maintain bone mass and even though swimming and biking are great exercise
techniques neither has been found to be effective in maintaining bone mass.
Situation: A client with Myasthenia Gravis is progressing toward respiratory failure. The Physician
ordered to undergo Plasmapheresis.
26. Which clinical manifestation would indicate a complication from this procedure?
A. Hypertension
B. Hypovolemia
C. Hyperkalemia
D. Hypercoagulopathy
Correct Answer: B
Plasmapheresis separates plasma from elements of the blood. The plasma is discarded and the packed
red blood cells are joined with albumin, normal saline, and electrolytes and then returned to the client. This
process reduces the amount of fluid and can, for a short while, improve the condition of someone in
respiratory failure. Hypovolemia is a potential complication from the procedure, although for the most part it
is rare. Because plasmapheresis removes extra plasma, hypertension is not an issue, and because the
packed red blood cells are returned with electrolytes, potassium levels are not elevated and there is no
evidence of hypercoagulopathy.
27. A nurse assigned in a private station is caring for a client diagnosed with Myasthenia gravis. What is
the priority nursing diagnosis for this client?
A. Ineffective Breathing Pattern
B. Impaired Mobility
C. Risk of Injury
D. Fatigue
Correct Answer: A
The client with myasthenia gravis has muscular weakness, which can and does affect the respiratory
muscles. The client can experience dyspnea and ineffective cough and swallow mechanisms, which may
lead to aspiration and pneumonia. Certainly the client can also experience the other nursing problems;
however, airway issues always take priority.
Situation: Nurses must be prepared to respond to Emergency cases and to specifically manage
health disaster situations.
28. A soldier wounded in a bombing attack in Mindanao using bombs has multiple lacerations and
bruises. The soldier begins to experience muscle weakness with an increased effort to breathe. The
client is diagnosed with Botulism. What is the minimum precaution the nurse should employ to
prevent the spread to others?
A. Standard precautions
B. Airborne precautions
C. Contact precautions
D. Droplet precautions
ANSWER: A - Although botulism toxin can be made in a format that can be loaded in bombs, the toxin is
not transmitted person to person, so nothing more than standard precautions is needed to provide care to
the client.
29. A young adult client with a head injury that occurred during a football game is brought to the
emergency department by friends. The client is disoriented to time and place. Treatment may be
given:
A. if the client consents to be treated.
B. with the consent of a family member.
C. under the implied emergency doctrine.
D. if the physician signs the consent form.
Correct Answer: C
The implied emergency doctrine allows emergency treatment to be given for a client who is unable to
consent under the assumption that the client would consent to avoid death or disability. The client is
disoriented and unable to give consent. The consent of a family member is not needed to provide
emergency care. Physicians are not authorized to consent to treatment for clients.
Situation: Susan 58 years old seeks admission and presents with bilateral lower extremity
weakness that began 3 hours ago and is progressively worsening.
30. What condition should the nurse suspect?

A. Myasthenia gravis
B. Guillain-Barré
C. Huntington's disease
D. Amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Characteristic of Guillain-Barré is ascending weakness, usually beginning in the lower extremities and
spreading sometimes rapidly to the trunk, upper extremities, and even the face. The weakness sometime
evolves over hours to days to weeks. Myasthenia gravis has as a main characteristic of increasing
weakness with sustained muscle contraction. Huntington's disease is known for the abnormal movements.
ALS affects the upper and lower motor neurons so there is muscle twitching and atrophy as well as
spasticity and hyperreflexia
31. Which of the following complications would the nurse be alert to Susan’s condition?
A. Muscle contractures
B. Pressure ulcer
C. Respiratory failure
D. Deep vein thrombosis (DVT)
Correct Answer: C
With Guillain-Barré syndrome, the muscle weakness is progressive and ascends so the nurse should be
worried about the client's respiratory function. Muscle contracture, pressure ulcers, and DVT are all
possible but are not the priority in this case.
32. A client is admitted with a possible medical diagnosis of Guillain-Barre syndrome. Which question is
most important for the nurse to ask the client?
A. Have you had an MMR immunization?
B. Have you had a recent upper respiratory infection?
C. Have you had any recent travel to Great Britain?
D. Have you been to China in the last two weeks?
Answer: B. Most clients with Guillain-Barre Syndrome will give a history of a mild febrile illness 1-3 weeks
prior to the onset of the neurological signs and symptoms. The predisposing febrile illness is usually a viral
upper respiratory or gastrointestinal infection. Recent travel and immunizations may be additional
information to gather.
33. A Head nurse is reviewing treatment options for a client diagnosed with Guillain-Barre syndrome.
Which procedure should the nurse discuss as a potential treatment option?
A. Hemodialysis C. Thrombolytic therapy
B. Plasmapheresis D. Immunosuppression therapy
Answer: B. (pg. 168) A client diagnosed with Guillain-Barre syndrome may have plasmapheresis as part of
treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of
its cellular components in an isotonic solution and the reinfusion of this solution.
Situation: A nurse is providing care for a 65-year-old male client with a recent total knee repair. The
wife of the client states how she hates that the flu season is just around the corner and that she
cannot afford to be sick this year with her husband recovering from knee surgery.
34. What intervention should the nurse suggest?

A. Stay indoors as much as possible.
B. Get vaccinated against the flu.
C. Take a vitamin supplement daily.
D. Drink plenty of fluids every day.
ANSWER: B - It is recommended for all adults older than age 50 to receive an annual influenza
vaccination. In addition, individuals who fall into the high-risk category also should have the vaccination
yearly. These individuals include but are not limited to persons with chronic health problems, people living
with other individuals at risk for contracting the flu, health care workers, and individuals living in an
institutional setting. Taking vitamin supplements and drinking plenty of water will certainly help but the
vaccination is the best method of prevention.
35. The nurse is providing care to a client with a head injury from hitting his head on a steering wheel.
The computed tomography (CT) scan results do not confirm a lesion. The client is experiencing
symptoms of increasing intracranial pressure ( ICP ). Which of the following interventions would the
nurse anticipate the Physician to order?
A. Mannitol bolus every 6 hours
B. Hypertonic saline intravenously (IV) at 30 mL/hr
C. Hyperventilation through mechanical ventilator
D. Decadron 60 mg IVP every 6 hours
Correct Answer: C
Brain swelling can come from a disruption in the blood-brain barrier, which occurs when edema is present.
This type of edema is very much like the edema that happens to a sprained ankle; the fluid contains
electrolytes, proteins, and blood. Another type of brain swelling comes from dilation of blood vessels. When
the brain swelling is caused by dilation of blood vessels, as in this scenario, the best method to reduce the
swelling is to constrict the vessels, which is done through controlled hyperventilation. Mannitol and
hypertonic saline would draw out fluid from the cells and pull the fluid into the vascular space, which is not
what is needed in this case. Decadron would reduce brain tissue swelling but does nothing to constrict the
blood vessels.
36. When the nurse is caring for a client who has suffered brain death, which of the following individuals
or groups is most appropriate to determine whether the client is medically eligible to be an organ
donor?
A. Family members
B. Primary physician
C. Hospital ethics committee
D. Organ procurement organization
Correct Answer: D
National guidelines indicate that the hospitals must have written protocols that ensure that an organ
procurement organization (OPO) is notified of deaths or imminent deaths so that hospital staff members are
not responsible for identifying possible organ donors. Family members, physicians, and the hospital ethics
committee are involved in the decision about organ donation, but the determination of medical eligibility is
made by staff from the OPO.
37. A client presents with rapid, purposeless hand movements. Based on this information, the nurse
would investigate further regarding what condition?
A. Parkinson’s disease
B. Myasthenia gravis
C. Guillain-Barré
D. Huntington’s disease
Correct Answer: D
Huntington's disease is characterized by rapid, jerky movements that become more pronounced and
involve all muscles. Parkinson's disease is characterized by hand tremor, slowness of movement, limb
stiffness, and difficulties with gait and balance. The main manifestation of myasthenia gravis is muscle
weakness with sustained muscle contraction. The main characteristic of Guillain-Barré syndrome is
ascending weakness.
38. The nurse is working with a client and her family regarding discharge. The client has Huntington's
disease (HD). The current discussion regards nutrition. What statement demonstrates the need for
additional education?
A. "Mom should eat canned peaches and mashed potatoes and gravy."
B. "Mom needs to cough after her swallowing to clear her throat."
C. "Mom should eat three large meals to reduce risk of aspiration."
D. "Mom needs to eat high-calorie foods at each and every meal."
Correct Answer: C
Mealtimes should be free of stress and clutter. Clients with HD should eat foods that form a bolus in the
mouth-like canned peaches and mashed potatoes and gravy. A high-calorie diet is required to replenish the
energy used during the day, and these clients should eat frequent, small meals. Clients with HD should sit
upright when eating and while swallowing; they should keep the chin down toward the chest and cough
after each mouthful to clear the throat of any residual food. The client with HD should not eat large meals
for the fear of aspiration.
Situation: A Senior nurse is providing care to a client with a diagnosis of exacerbation of Multiple
Sclerosis (MS).
39. The Nurse is promoting self-care with the goal of reducing fatigue. What intervention should the
nurse implement?
A. Give the client a bed bath in the morning.
B. Encourage the client to complete range-of-motion (ROM) exercises.
C. Cluster care in the morning so the client can rest in the afternoon.
D. Provide the client with a high-energy supplement shake.
Correct Answer: B
Fatigue is a common manifestation of MS and usually one of the most disabling. Encouraging the client to
complete ROM exercises keeps the muscle from weakening from nonuse. Although the client's ability to
complete tasks deteriorates as the task is worked on, it is important for the client to do as much for herself
as possible to help reduce depression.
40. A 36-year-old female reports double vision, visual loss, muscular weakness, numbness of the hands,
fatigue, tremors, and incontinence. Based on this report, what does the nurse suspect?
A. Parkinson’s disease C. Amyotrophic sclerosis (ALS)
B. Myasthenia Gravis (MG) D. Multiple sclerosis (MS)
Rationale: D. These are symptoms of MS, which is more common in women ages 20 – 40.
Reference: NCLEX-RN Review 6th Edition by: Rebecca Caldwell Oglesby, 2010
Situation: A young male client comes into the emergency department complaining of his heart
"racing," a fluttering feeling in his chest, and seeing stars. He states that during these attacks he
can hardly breathe. He believes he is having a heart attack. He admits using recreational drugs
once in a while but has not used any since last week.
41. What nursing diagnosis should the nurse make as a priority?

A. Impaired Tissue Perfusion
B. Anxiety
C. Ineffective Airway Clearance
D. Fear
ANSWER: B - The acute manifestations of a panic attack, which is a subtype of the anxiety disorders, can
create severe physical distress. These symptoms are palpitations, chest pain, elevated vital signs,
dizziness, nausea, and distinct fear that one is dying. The client is experiencing classic symptoms. The
client is not having a heart attack; he is not complaining of chest pain or any other pain. The client does use
recreational drugs and depending on the drug that could predispose the client to a potential heart attack but
this usually happens within a short time of using the drug. Even though the client has shortness of breath
due to his anxiety, he does have a clear and patent airway.
Situation: Alzheimer’s disease needs a special kind of attention because of the disturbed thought
and processes. A staff nurse admitted a client with advance stage Alzheimer's disease says that no
one has helped her clean up today.
42. The nurse witnessed the novice nurse helping the client this morning wash up. How should the nurse
respond?
A. "You are confused. I saw the nursing assistant assist you this morning."
B. "The novice nurse documented the completion of morning care 2 hours ago."
C. "Let me get you a warm wash cloth and towel to wash up with."
D. "You look tired after being up for 2 hours, maybe a nap would help."
Correct Answer: C
Manifestations of multi-infarct dementia often develop in a stepwise manner and include confusion,
problems with recent memory, wandering, or getting lost in familiar places. Even though explaining to the
client that she has already received care regarding personal hygiene, with the lack of recent memory, the
client does not and will not remember the encounter, so the best intervention is to provide the washcloth
and towel so the client can clean up.
43. A novice nurse is assisting a client with Alzheimer's disease in her activities of daily living. The novice
nurse is extremely frustrated with the client's persistent incontinence and is discussing the issue with
the senior nurse. What intervention should be added to the client's plan of care?
A. Reorient the client to her surroundings every 2 hours as needed.
B. Discuss the incontinence episodes with the client to develop mutual interventions.
C. Assist the client to the bathroom every 2 hours, documenting results.
D. Request an order to insert an indwelling catheter after the next incontinence episode.
Correct Answer: C
Clients in the middle stage of Alzheimer's develop both urinary and bowel incontinence in the absence of
pathology. Developing scheduled voiding and defecation times can help in the initial stages. Reorienting
the client and attempting to develop mutual goals at this stage is not beneficial. Requesting an indwelling
catheter is not beneficial to the client because it sets up the client for injury and infection.
44. A client with moderate Alzheimer's disease is being discharged home to stay with his son and his
family. The nurse is providing education on what the family could expect. What statement validates
the need for additional education?
A. We will see an improvement in dad once he is home for a few days.
B. Keeping the doors locked will help prevent dad from wandering.
C. If we remove potential hazards from our home, we can leave dad to run errands.
D. As the disease progresses, dad might revert back to infancy, putting everything in his mouth.
Correct Answer: C
The client with Alzheimer's disease has disturbed thought process and should not be left alone even with
the house as safe as possible and the doors locked so the client cannot wander off. The family should see
a little improvement in the client's behavior after the client gets used to the environment again. The
remaining options are true.
45. A client with moderate Alzheimer's disease has a language disturbance, palilalia. Based on this
information, what intervention should the nurse implement to improve communication with the client?
A. Speak in a firm tone, repeating instructions several times.
B. Speak in a calm tone, repeating instructions using variation of terms.
C. Speak in a firm tone, allowing time for the client to repeat what she has heard.
D. Speak in a calm tone, allowing time for the client to repeat what she has said.
Correct Answer: D
Palilalia is characterized by the client repeating words or phrases that either the client has just said or that
someone else has just said. To provide the best communication with the client, the nurse should speak
clearly and calmly, and allow for the client to repeat either what she has heard or what she has said. Using
a firm tone usually is not beneficial when communicating with clients with Alzheimer's disease.
Situation: A 25-year-old male client is admitted to the hospital with the diagnosis of schizophrenia.
The client is sitting in the chair near the bed holding the pillow and watching the door. When the
nurse enters to complete the history form, the client warns the nurse to stay away or he will burn.
46. Which intervention is the best method to obtain the information for the nursing history?
A. Allow the client to determine the distance between the client and the nurse.
B. Maintain a calm facial expression when the client discusses his delusions.
C. Request the client contact his mother and include her in the interview.
D. Allow the client to discuss his beliefs without challenging his reality.
ANSWER: C - A client with schizophrenia experiences delusions and hallucinations. The communication
skills are profoundly affected and the client's reality is skewed. The nurse must get a complete and
thorough history that includes the client's psychosocial history in order for the client to receive the best care
and the best resources in the community. The next reliable person to obtain the information from would be
the client's family. The remaining options are valid interventions that should be used when addressing this
client, but these options will not assist in gathering of the nursing history.
47. What nursing diagnosis would be the priority for clients with Schizophrenia ?
A. Impaired Communication
B. Altered Thought Process
C. Potential for Injury
D. Activity Intolerance
ANSWER: C - A client experiencing positive manifestations of schizophrenia has symptoms of auditory or
visual hallucinations, delusions, and disorganized thinking and speech. With the client experiencing
hallucinations, the potential for injury is the priority diagnosis. Then the nurse should worry about altered
thought process and communication. Usually this type of client does not have an activity intolerance
problem, although a client experiencing negative manifestations would experience activity intolerance.
48. The nurse is completing her assessment on a 45-year-old woman with a diagnosis of Schizophrenia.
The client's mother is present and she dominates most of the conversation answering questions for
her daughter. The client is most worried about a little white kitten that only she sees that is walking
around the room crying for its mother. The nurse is aware that the client is having hallucinations.
What action should the nurse take?
A. Direct all conversation to the mother at this point so the assessment information is accurate.
B. Sit next to the client, restate her hallucination for accuracy, then reorient the client to the reality.
C. Document the findings, then alert the physician so adjustment can be made to her medications.
D. Record the client’s comments without challenging or agreeing with the reality of the
remarks.
ANSWER: D - It is of great importance to have a complete assessment, which includes the comments from
the client. The nurse should listen and record the comments from the client without passing judgment or
challenging the reality of the client's comments. At this point, it is not the nurse's responsibility to reorient
the client to the nurse's reality. If the nurse allows all of the data to be collected by asking the mother the
questions, then the health care team may miss data that would assist in developing a treatment plan. After
the information is documented, there may be a change in the client's medication but it is not the first thing
that happens. A nurse should never invade a client's space without permission.

49. The nurse is developing a plan of care for a young client diagnosed with Schizophrenia having
negative manifestations. Which nursing diagnosis is priority?
A. Fatigue
B. Social Isolation
C. Self-Care Deficit
D. Anxiety
ANSWER: B - A young adult normally struggles with personal identity and how he or she fits into the world.
When a client with schizophrenia has negative manifestations, the client is withdrawn, has a blunt affect,
has a lack of energy, and lacks motivation. At a young age social isolation is devastating. This could lead to
further negative thoughts and potentially suicide. The client will indeed be fatigued and thus lacking energy
to care for himself; however, this is not a priority at this time. The client will probably not experience anxiety
as a result of these manifestations.
50. When you administer a typical antipsychotic agents ordered by the psychiatrist to a client who has
Schizophrenia, you realize that this medication is most likely to do which of the following things?
A. Increase the activity of dopamine C. Increase the reuptake of serotonin
B. Decrease the activity of dopamine D. Have no effect on dopamine activity
Answer: B. In schizophrenia and mania, there is hyperactivity of dopaminergic systems that must be
tempered or reduced. In Parkinson’s disease and depression, it is believed that the dopamine systems are
hypoactive and, therefore, medications in those conditions increase dopamine availability to the body.
Reference: Psychiatric Nursing by Sheila Videbeck
51. After assessing a client, the nurse suspects this client has Bulimia Nervosa. Which of the following
symptoms best alerted the nurse to be suspicious that this client has Bulimia Nervosa?
A. Overweight C. Erosion of dental enamel
B. Underweight D. Sunken eyes and cheeks
Answer: C. Clients with bulimia can have a normal weight, be overweight, or underweight. These clients
often have swollen cheeks due to enlarged salivary glands. The repeated vomiting causes erosion of the
dental enamel.
52. When working with clients with disorders, the nurse is aware that eating disorder differs from Bulimia
Nervosa in that people suffering from a binge eating disorder:
A. Do not engage in purging or compulsive exercise
B. Have joined at least two weight reduction programs
C. Weight at least two times the normal weight for height
D. Do not have impairment in work and social functioning
Answer: A. The major difference between binge eating and bulimia nervosa is that the person with binge
eating disorder does not engage in the purging or compulsive exercise. The focus for the client with bulimia
is to lose weight, while the binge eater is fulfilling some unmet need.
53. Your client has eating disorder and a history of excessive laxative use in an attempt to lose weight. A
primary health concern related to the laxative use is which of the following?
A. Electrolyte imbalance C. Impaired mobility
B. Respiratory insufficiency D. Knowledge deficit
Answer: A. The primary health concern related to the excessive use of laxatives is an electrolyte
imbalance. Laxatives cause the body to not only eliminate digested food but also to eliminate water. As
water is eliminated, it pulls with it both sodium and potassium. A reduction in potassium can cause cardiac
arrhythmias.
54. A nurse is caring for an anorexic client with a nursing diagnosis of Imbalanced nutrition: Less than
body requirements related to dysfunctional eating patterns. The following interventions would be
supportive for this client except:
A. provide small, frequent meals
B. monitor weight gain
C. allow the client to skip meals until the antidepressant levels are therapeutic
D. monitor the client during meals and for 1 hour afterward
Rationale: C. Because they’re engaged in self-starvation, clients with anorexia rarely can tolerate large
meals three times per day. Small, frequent meals may be tolerated better and they provide a way to
gradually increase daily caloric intake. The nurse should monitor the client’s weight carefully because a
client with anorexia nervosa may try to hide her weight loss. The nurse should also monitor the client during
meals ad for 1 hour afterward to ensure that she consumes all of her food and doesn’t attempt to purge.
The client may be afraid to express her feelings; keeping a journal can serve as an outlet for these feelings,
which can assist recover. A client with anorexia is already underweight and shouldn’t be permitted to skip
meals.
55. During the oral assessment of a 24-year-old client seen in the outpatient clinic with Amenorrhea, the
nurse notes that the client has eroded enamel on her teeth. Based on these assessments, which
question should the nurse ask next?
A. "How much do you exercise daily?"
B. "Do you follow a vegetarian diet?"
C. "Do you ever vomit after eating?"
D. "How much milk do you drink?"
Correct Answer: C
The client's symptoms of amenorrhea and erosion of the tooth enamel are consistent with a diagnosis of
bulimia. The other questions do not address the assessment data obtained by the nurse.
Situation: A female client is admitted to the hospital for an elective surgical procedure. During the
admission history and physical, the client states that she drinks socially during the week and over
the weekend. An understanding of patterns of alcohol is essential in the history and health practice.
56. Which statement leads the nurse to think that the client may have alcohol addiction?
A. "I meet my friends after work and on the weekends to unwind and relax."
B. "I was stopped by police for driving under the influence last year."
C. "I have at least one drink every day, either with someone or by myself at home."
D. "I like to do a lot of fine needlepoint and the alcohol keeps my hands steady."
ANSWER: D - Tremors, anorexia, insomnia, anxiety, and restlessness are early symptoms of alcohol
withdrawal.
57. A 25-year-old male client is being transferred from the emergency department to the intensive care
unit after being diagnosed with a Barbiturate overdose. What is the priority nursing diagnosis?
A. Impaired Tissue Perfusion
B. Ineffective Breathing Pattern
C. Decreased Cardiac Output
D. Ineffective Airway Clearance
ANSWER: B - Barbiturates are a central nervous system depressant, so the nurse would expect that the
respiratory rate would be low and that both the rate and the depth would need to be monitored. The primary
diagnosis then is Ineffective Breathing Pattern because breathing comes before circulation. When
determining nursing diagnoses, the nurse should work on the priority diagnosis; however, sometimes
students have difficulty deciding how to determine priority. So, using ABC (airway, breathing, circulation) is
one method to determine priority; another would be deciding which issue would cause harm to the patient
first. The answer is correct because both the Airway before circulation and breathing are affected. It is
common that students have trouble identifying which diagnosis is most appropriate, so an explanation of
why Airway clearance is not the answer is appropriate and the circulation diagnoses are not discussed, as
the failure of the circulatory system would come after the failure of the respiratory system. Barbiturates
cause respiratory depression. Ineffective Airway Clearance does not have any support in the scenario so it
is not a factor. The rate is decreased and so is the effort.
58. A nurse has developed a relationship with a client who has an addiction problem. The following
actions would indicate that the therapeutic intervention is in the working phase except:
A. the client discusses how the addiction has contributed to family distress
B. the client verbalizes difficulty identifying personal strengths
C. the client discusses the financial problems related to the addiction
D. the client expresses uncertainty about what topic to discuss
Rationale: D. Acknowledging the addiction’s effects on the family and discussing its financial impact will
help the client to identify personal strengths in dealing with addiction and strengthen the therapeutic
relationship in the process. Discussing the family history of addiction and expressing uncertainty about
what topics to address with the nurse typically happen during the introductory phase of a nurse-client
relationship.
59. The school nurse teaching parents about alcohol and other drug abuse will advise parents that the
most used and abused substance in all age group is:
A. Alcohol C. Marijuana
B. Inhalants D. Amphetamines
Answer: A. In a national household survey on drug abuse reported in 2000, alcohol was found to be the
most used and abused substance in all age groups. Alcohol and drug use have become a part of the youth
experience in America.
Situation: The nurse is providing care to a client with Parkinson's disease. Increasing mobility is a
goal in this client's plan of care. Physical therapy and occupational therapy is involved with this
client. The client has 0900 meds to improve his mobility. Therapy begins at 1050.
60. The nurse should administer the medication at:

A. 0900.
B. 0940.
C. 1000.
D. 1050.
Correct Answer: C
Activities of daily living or exercise should be performed when the drugs are working well to avoid injury to
the client and caregiver, so the medication is best to be given at 1000. If the medication is given earlier, the
medication may already have peaked, and giving the medication at the time of therapy does not allow for
the drug to be metabolized into the system.
61. Another client with Parkinson's disease was recently offered early retirement from his company. He
presents today with an exacerbation of tremors, rigidity, and bradykinesia. He is diaphoretic and
experiencing tachycardia. The nurse should:
A. check the client's serum blood glucose level.
B. place the client in a quiet room and subdued lighting.
C. encourage the client to take slow deep breaths.
D. prepare to start intravenous fluids and electrolytes.
Correct Answer: B
Occasionally clients who experience emotional trauma or sudden or inadvertent withdrawal of medication
experience a crisis, experiencing severe tremors, bradykinesia, and rigidity. The client should be placed in
a dimly lit room that is quiet so he can begin to calm down. The client's glucose level is not relevant in this
scenario, and the best intervention is for the client to calm down without additional stimuli. The symptoms
are from the exacerbation and not an imbalance of electrolytes, so fluids are not necessary.
62. The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy
infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain this
assessment data?
A. Masklike facies and shuffling gait
B. Difficulty swallowing and immobility
C. Pill rolling of fingers and flat affect
D. Lack of arm swing and bradykinesia
Answer: B.
Rationale:
A. Masklike facies is responsible for lack of expression and is part of motor manifestations of
Parkinson’s disease but is not related to the symptoms listed. Shuffling is also a motor deficit and
does pose a risk for falling, but fever and patchy infiltrates on a chest x-ray do not result from a gait
problem. They are manifestations of a pulmonary complication.
B. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client
to pneumonia. Both clinical mainfestations place the client at risk for pulmonary
complications.
C. Pill rolling of fingers and flat affect do not ave an impact on the development of pulmonary
complications.
D. Arm swing and bradykinesia are motor deficits.

63. The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of “impaired
nutrition.” Which nursing intervention would be included in the plan of care?
A. Consult the occupational therapists for adaptive appliances for eating
B. Request a low-fat, low-sodium diet from the dietary department
C. Provide three meals per day that include nuts and whole-grain breads
D. Offer six meals per day with a soft consistency
Answer: D.
Rationale:
A. Adaptive appliances will not help the client’s shaking movements and are not used for clients with
Parkinson’s disease.
B. Clients with Parkinson’s disease are placed on high-calorie, high-protein, soft or liquid diets.
Suuplemental feedings may also be ordered. If liquids are ordered because of difficulty chewing, then
the liquids should be thickened to a honey or pudding consistency.
C. Nuts and whole-grain food would require extensive chewing before swallowing and would not be
good for the client. Three large meals would get cold before the client can consume the meal and
one half or more of the food would be wasted.
D. The client’s energy levels will not sustain eating for long periods. Offering frequent and easy-
to-chew (soft) meals of small proportions is the preferred dietary plan.
64. Which is a common cognitive problem associated with Parkinson’s disease?

A. Emotional lability C. Memory deficits
B. Depression D. Paranoia
Answer: C.
Rationale:
A. Emotional lability is a psychosocial problem, not a cognitive one.
B. Depression is a psychosocial problem.
C. Memory deficits are cognitive impairments. The client may also develop a dementia.
D. Paranoia is a psychosocial problem.
Situation: A client with Alzheimer's disease was admitted to the hospital 4 days ago. Upon
admission, the client was pleasant, calm, and cooperative. Today the client is agitated, mean, and
restless and has started to wander at night.
65. The nurse is revising the plan of care. What intervention should the nurse implement?
A. Place the patient in a soft jacket restraint for 30 minutes before the sun sets.
B. Have the client take a 2-hour nap every afternoon from 1 to 3 o'clock.
C. Limit caregiver-initiated awakenings during the night for toileting.
D. Encourage the client to have a large, warm cup of tea before bed.
ANSWER: C - The most typical pattern with dementia is frequent awakenings with agitation progressing to
loss of sleep/wake consolidation. Minimizing caregiver-initiated awakenings for things like toileting and
ensuring a regular bedtime with a bedtime routine may help reduce nocturnal and daytime agitation.
Restraints should be avoided because the restraint often poses a safety risk to an agitated patient.
Providing a daytime nap may not prevent the mood issues or increase the client's restful sleep. It would be
a better idea to establish a routine and a bedtime. Caffeine should be avoided when individuals are having
trouble falling asleep or even staying asleep because it interferes with this process.

66. A 23-year-old client is preparing for finals at a local university. He works long hours, attends classes,
and studies in between. The client arrives at the clinic with a panic attack and overwhelming anxiety.
The client denies alcohol or recreational drug use. What statement during the interview leads the
nurse to suspect substance abuse?
A. "The employees at the local coffee shop know me well."
B. "Coffee in the morning relieves the morning headache."
C. "My hands tremble at times but they stop when I move them."
D. "With a little caffeine, I can study all night and go to class."
ANSWER: B - The lack of caffeine can lead to a severe headache anytime of the day but when the body
has not had caffeine, for instance during sleep, then a morning headache is definitely a possibility. Coffee
shops are local "hangouts" for college students, so this is not a definitive clue that the client is addicted to
caffeine. The manifestations of hand trembling or having fine tremors that dissipate when moving are more
the manifestation of a neuromuscular disease. The idea that the client can take some caffeine and then
study all night does not in itself raise suspicion of abuse. These terms are being used interchangeably
because college students do occasionally drink caffeine to study.
67. When assessing an unconscious patient the nurse observes frowning, grimacing, and restlessness.
What symptoms do these indicate?
A. Anxiety
B. Dreaming
C. Pain
D. Terminal agitation
ANSWER: C - When patients are nonverbal, behavioral indicators of pain should be assessed.
68. A 56-year-old male client has a history of anxiety disorder and is currently having surgery for lysis of
adhesions from previous cholecystectomy. The client is pacing the floor; his vital signs are stable but
a little elevated. He states to the nurse that he does not understand why he has to wait so long, he
was supposed to be here at 0630 for an 0700 procedure and it is now 0730 and he is still waiting.
What action should the nurse implement next?
A. The nurse should explain to the client that she will leave to contact the surgical team for
an update on his procedure and then return when she has an answer.
B. The nurse should allow the client to voice his disappointment for having to wait and then leave
the room, returning only at the client's request.
C. The nurse should inform the client that the surgical team must be running late this morning and
that the team will call when they are ready for the client.
D. The nurse should provide an update to the charge nurse regarding the client’s anxiety, then
request a sitter to stay with the client until it is time for his surgical procedure.
ANSWER: A - It is important for the nurse to provide a supportive atmosphere and to explain the limitations,
if any, with the nurse's interaction. For example, "I may only have 15 minutes before I am interrupted." The
client is aware then of what might happen. In this scenario, the nurse leaves the client, but not because she
is avoiding the situation. She makes this known to the client with a definite returning point. The sitter may
be an option to assist the client if providing the client with updated information does not reduce some of the
anxiety or if there continues to be changes in the client's time for the procedure. It is always good to allow
clients to vent their feelings, but in this case some sort of action is necessary.
Situation: The role of the Psychiatric nurse is both rewarding and challenging. Responding to
client’s special needs truly fulfills their nursing practice. Nurse Angel is admitting a client with
Bipolar disorder is pacing in the hall, talking loudly, rapidly, and using elaborate hand gestures.
69. The nurse concludes that the client is demonstrating which of the following?
A. Aggression
B. Anger
C. Anxiety
D. Psychomotor agitation
Answer: D
70. A client with bipolar disorder begins taking lithium carbonate (lithium), 300 mg four times a day. After
3 days of therapy, the client says, “My hands are shaking.” The best response by the nurse is:
A. “Fine motor tremors are an early effect of lithium therapy that usually subsides in a few
weeks.”
B. “It is nothing to worry about unless it continues for the next month.”
C. “Tremors can be an early sign of toxicity, but we’ll keep monitoring your lithium level to make
sure you’re okay.”
D. “You can expect tremors with lithium. Yu seemed very concerned about such a small tremor.”
Answer: A
71. What are the most common types of side effects from Selective Serotonin Reuptake Inhibitors
(SSRIs)?
A. Dizziness, drowsiness, dry mouth
B. Convulsions, respiratory difficulties
C. Diarrhea, weight gain
D. Jaundice, agranulocytosis
Answer: A
Situation: A Mental Health Psychiatric Nurse is reviewing the significant behaviors and other cues
of clients with Depression and other Personality disorders, for further evaluation and management.
72. The nurse observes that a client with depression sat at a table with two other clients during lunch.
The best feedback the nurse could give the client is :
A. “Do you feel better after talking with others during lunch?”
B. “I’m so happy to see you interacting with other clients.”
C. “I see you were sitting with others at lunch today.”
D. “You must feel much better than you were a few days ago.”
Answer: C

73. As a Mental Health Nurse which of the following clients you would observe that typifies the speech of
a person in the acute phase of Mania?
A. Flight of ideas
B. Psychomotor retardation
C. Hesitant
D. Mutism
Answer: A
74. When working with a client with Paranoid Personality disorder, the nurse would use which of the
following approaches?
A. Cheerful
B. Friendly
C. Serious
D. Supportive
Answer: C
75. Which of the following underlying emotions is commonly seen in a Passive-Aggressive personality
disorder?
A. Anger
B. Depression
C. Fear
D. Guilt
Answer: A
76. Nursing Psychiatric Management focus on the Cognitive restructuring techniques which include all
the following except:
A. Decatastrophizing
B. Positive self-talk
C. Reframing
D. Relaxation
Answer: D
77. The nurse would assess for which of the following characteristics of a client in the ward with
Narcissistic personality disorder?
A. Entitlement
B. Fear of abandonment
C. Hypersensitivity
D. Suspiciousness
Answer: A
78. The most important short-term goal for the client who tries to manipulate others would be to :
A. Acknowledge own behavior
B. Express feelings verbally
C. Stop initiating arguments
D. Sustain lasting relationships
Answer: A
Situation: The Psychiatric Nurse has different roles and functions in a variety setting.
79. The nurse is caring for a client with Conversion Disorder. Which of the following assessments will the
nurse expect to see?
A. Extreme distress over the physical symptoms
B. Indifference about the physical symptom
C. Labile mod
D. Multiple physical complaints
Answer: B
80. Which of the following statements would indicate that teaching about Somatization disorder has been
effective?
A. “The doctor believes I am faking my symptoms.”
B. “If I try harder to control my symptoms, I will feel better.”
C. “I will feel better when I begin handling stress more effectively.”
D. “Nothing will help me feel better physically.”
Answer: C
81. Emotion-focused coping strategies are designed to accomplish which of the following outcomes?
A. Helping the client mange difficult situations more effectively
B. Helping the client manage the intensity of symptoms
C. Teaching the client the relationship between stress and physical symptoms
D. Relieving the client’s physical symptoms
Answer: B
82. Which of the following is true about clients with Hypochondriasis?

A. They may interpret normal body sensations as signs of disease.
B. They may exaggerate or fabricate physical symptoms for attention.
C. They do not show signs of distress about their physical symptoms.
D. All the above are true statements.
Answer: A
83. The client’s family asks the nurse, “What is hypochondriasis?” The best response by the nurse is,
“Hypochondriasis is
A. A persistent preoccupation with getting a serious disease.”
B. An illness not fully explained by a diagnosed medical condition.”
C. Characterized by a variety of symptoms over a number of years.”
D. The eventual result of excessive worrying about diseases.”
Answer: A
84. A client with somatization disorder has been attending group therapy. Which of the following
statements indicates that therapy is having a positive outcome for this client?
A. “I feel better physically just from getting a chance to talk.”
B. “I haven’t said much, but I get a lot from listening to others.”
C. “I shouldn’t complain too much; my problems aren’t as bad as others.”
D. “The other people in this group have emotional problems.”
Answer: A
85. The nurse would expect to see all the following symptoms in a child with ADHD except :
A. Easily distracted and forgetful
B. Excessive running, climbing and fidgeting
C. Moody sullen and pouting behavior
D. Interrupts others and can’t take turns
Answer: C
Situation: Te following are different situations and concerns of clients in the Psychiatric ward which
requires therapeutic management.
86. Which of the following is normal adolescent behavior?

A. Critical of self and others
B. Defiant, negative and depressed behavior
C. Frequent hypochondriacal complaints
D. Unwillingness to assume greater autonomy
Answer: A
87. Which f the following is used to treat enuresis?

A. Imipramine (Tofranil)
B. Methylphenidate (Ritalin)
C. Olanzapine (Zyprexa)
D. Risperidone (Risperdal)
Answer: A
88. An effective nursing intervention for the impulsive and aggressive behaviors that accompany conduct
disorder is:
A. Assertiveness training
B. Consistent limit setting
C. Negotiation of rules
D. Open expression of feeling
Answer: B
89. The nurse recognizes which of the following as a common behavioral sign of Autism?
A. Clinging behavior toward parents
B. Creative imaginative play with peers
C. Early language development
D. Indifference to being hugged or held
Answer: D
90. The nurse is talking to a woman who is worried that her mother has Alzheimer’s disease. The nurse
knows that the first sign of dementia is:
A. Disorientation to person, place or time
B. Memory loss that is more than ordinary forgetfulness
C. Inability t perform self-care tasks without assistance
D. Variable with different people
Answer: B
91. The nurse has been teaching a caregiver about Donepezil (Aricept). The nurse knows that teaching
has been effective by which of the following statements?
A. “Let’s hope that this medication will stop the Alzheimer’s disease from progressing any further.”
B. “It is important to take this medication on an empty stomach.”
C. “I’ll be eager too see if this medication makes any improvement in concentration.”
D. “This medication will slow the progress of Alzheimer’s disease temporarily.”
Answer: D
92. Which of the following statements by the caregiver of a client newly diagnosed with Dementia
requires further intervention by the nurse?
A. “I will remind Mother of things she has forgotten.”
B. “I will keep Mother busy with favorite activities as long as she can participate.”
C. “I will try to find new and different things to do every day.”
D. “I will encourage Mother too talk about her friends and family.”
Answer: C
93. A client with Delirium is attempting to remove the intravenous tubing from his arm, saying o the
nurse, “Get off me! Go away!” The client is experiencing which of the following?
A. Delusions
B. Hallucinations
C. Illusions
D. Disorientation
Answer: B

94. Which of the following interventions is most appropriate in helping a client with early-stage Dementia
complete activities of daily living (ADLs)?
A. Allow enough time for the client to complete ADLs as independently as possible
B. Provide the client with a written list of all the steps needed to complete ADLs.
C. Plan to provide step-by-step prompting to complete the ADLs
D. Tell the client to finish ADLs before breakfast or the nursing assistant will d them.
Answer: A
Situation: A Nurse is expected to establish a sound nurse patient relationship, utilizing a

therapeutic communication to determine the health problems of the clients especially with
behavioral concerns.
95. A nurse made her rounds and observed a client, “Earlier today you said you were concerned that
your son was still upset with you. When I stopped by your room about an hour ago, you and your son
seemed relaxed and smiling as you spoke to each other. How did things go between the two of you?”
This is an example of which therapeutic communication technique?
A. Consensual validation
B. Encouraging comparison
C. Accepting
D. General lead
Answer: A
96. A client came to a new nurse and complained about the other nurse. The nurse ask her , “Why do
you always complain about the night nurse?” She is a nice woman and a fine nurse and has five kids
to support. You’re wrong when you said she is noisy and uncaring.” This example reflects which non
therapeutic technique?
A. Requesting an explanation
B. Defending
C. Disagreeing
D. Advising
Answer: B
97. As a Nurse how do you evaluate these exchanges of communication between a Client and a Nurse?
Client: “I was so upset about my sister ignoring my pain when I broke my leg.”
Nurse: “When are you going to your next diabetes education program?
This is a non therapeutic response because the nurse has:
A. Used testing t evaluate the client’s insight
B. Changed the topic
C. Exhibited an egocentric focus
D. Advised the client what to do
Answer: B

98. A client has a prescription for Haloperidol, 5 mg orally, two times a day, as ordered by the Physician.
The client is suspicious and refuses to take the medication. The nurse says, “If you don’t take this pill,
I’ll get an order to give you an injection.” The nurse’s statement is an example of :
A. Assault
B. Battery
C. Malpractice
D. Unintentional tort
Answer: A
99. A hospitalized client is delusional, yelling “The world is coming to an end. We must all run to safety!”
When other clients complain that this client is loud and annoying, the nurse decides to put the client
in seclusion. The client has made no threatening gestures or statements to anyone. The nurse’s
action is an example of :
A. Assault
B. False imprisonment
C. Malpractice
D. Negligence
Answer: B
100. Which of the following would indicate a duty to warn a third party?
A. A client with delusion states, “I’m going to get them before they get me.”
B. A hostile client says, “I hate all police.”
C. A client says he plans to blow up the federal government
D. A client states, “If I can’t have my girlfriend back, then no one can have her.”
Answer: D


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vanguardia’s online review program

5. A postoperative client has undergone an Ossiculoplasty. What nursing diagnosis is of priority?

© National Library of the Philippines, April 2015 3

Situation: In a Rehabilitation facility medical and nursing interventions were immediately

30. What condition should the nurse suspect?

34. What intervention should the nurse suggest?

41. What nursing diagnosis should the nurse make as a priority?

© National Library of the Philippines, April 2015 15

60. The nurse should administer the medication at:

© National Library of the Philippines, April 2015 19

64. Which is a common cognitive problem associated with Parkinson’s disease?

© National Library of the Philippines, April 2015 20

© National Library of the Philippines, April 2015 22

82. Which of the following is true about clients with Hypochondriasis?

86. Which of the following is normal adolescent behavior?

87. Which f the following is used to treat enuresis?

© National Library of the Philippines, April 2015 26

Situation: A Nurse is expected to establish a sound nurse patient relationship, utilizing a

© National Library of the Philippines, April 2015 27

© National Library of the Philippines, April 2015 28

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