Question 1

WRONG
Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is
aware that the following conditions might the drug be administered?

Phencyclidine (PCP) intoxication

Alcohol withdrawal

Opiate withdrawal

Cocaine withdrawal

Question 1 Explanation:
Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as
chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat
alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat
PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain,
such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

Question 2
WRONG
A male adult client voluntarily admits himself to the substance abuse unit. He confesses that
he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that
afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this
condition?

Vomiting, diarrhea, and bradycardia

Dehydration, temperature above 101° F

(38.3° C), and pruritus

Hypertension, diaphoresis, and seizures

Diaphoresis, tremors, and nervousness

Question 2 Explanation:
Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and
alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include
diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure
and pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of
alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal.
Dehydration and an elevated temperature may be expected, but a temperature above 101°
F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol
withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.
Question 3
WRONG
In the emergency department, a client with facial lacerations states that her husband beat
her with a shoe. After the health care team repairs her lacerations, she waits to be seen by
the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the
client’s husband arrives, shouting that he wants to “finish the job.” What is the first priority of
the health care worker who witnesses this scene?

Remaining with the client and staying

calm

Calling a security guard and another staff

member for assistance

Telling the client’s husband that he must

leave at once

Determining why the husband feels so

angry

Question 3 Explanation:
The health care worker who witnesses this scene must take precautions to ensure personal
as well as client safety, but shouldn’t attempt to manage a physically aggressive person
alone. Therefore, the first priority is to call a security guard and another staff member. After
doing this, the health care worker should inform the husband what is expected, speaking in
concise statements and maintaining a firm but calm demeanor. This approach makes it
clear that the health care worker is in control and may diffuse the situation until the security
guard arrives. Telling the husband to leave would probably be ineffective because of his
agitated and irrational state. Exploring his anger doesn’t take precedence over safeguarding
the client and staff.

Question 4
WRONG
A female client with anorexia nervosa describes herself as “a whale.” However, the nurse’s
assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg).
Considering the client’s unrealistic body image, which intervention should nurse Angel be
included in the plan of care?

Asking the client to compare her figure

with magazine photographs of women
her age

Assigning the client to group therapy in

which participants provide realistic
feedback about her weight
 Confronting the client about her actual
appearance during one-on-one sessions,
scheduled during each shift

Telling the client of the nurse’s concern

for her health and desire to help her
make decisions to keep her healthy

Question 4 Explanation:
A client with anorexia nervosa has an unrealistic body image that causes consumption of
little or no food. Therefore, the client needs assistance with making decisions about health.
Instead of protecting the client’s health, options A, B, and C may serve to make the client
defensive and more entrenched in her unrealistic body image.

Question 5
WRONG
A 24-year old client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate
what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with the
client’s distorted perceptions and feelings?

Avoid discussing the client’s perceptions

and feelings

Focus discussions on food and weight

Avoid discussing unrealistic cultural

standards regarding weight

Provide objective data and feedback

regarding the client’s weight and
attractiveness

Question 5 Explanation:
By focusing on reality, this strategy may help the client develop a more realistic body image
and gain self-esteem. Option A is inappropriate because discussing the client’s perceptions
and feeling wouldn’t help her to identify, accept, and work through them. Focusing
discussions on food and weight would give the client attention for not eating, making option
B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards
wouldn’t help the client establish more realistic weight goals.

Question 6
WRONG
A male client is brought to the psychiatric clinic by family members, who tell the admitting
nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During
an interview with the nurse Linda, which statement by the client most strongly supports a
diagnosis of psychoactive substance abuse?

“I’m not addicted to alcohol. In fact, I can

drink more than I used to without being
affected.”

“I only spend half of my paycheck at the

bar.”

“I just drink to relax after work.”

“I know I’ve been arrested three times

for drinking and driving, but the police
are just trying to hassle me.”

Question 6 Explanation:
According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition,
diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such
use, indicated either by continued use despite knowledge of having a persistent or recurrent
social, occupational, psychological, or physical problem caused or exacerbated by
substance abuse or recurrent use in dangerous situations (for example, while driving). For
this client, psychoactive substance dependence must be ruled out; criteria for this disorder
include a need for increasing amounts of the substance to achieve intoxication (option A),
increased time and money spent on the substance (option B), inability to fulfill role
obligations (option C), and typical withdrawal symptoms.

Question 7
WRONG
A male client is hospitalized with fractures of the right femur and right humerus sustained in
a motorcycle accident. Police suspect the client was intoxicated at the time of the accident.
Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to
drinking heavily for years. During hospitalization, the client periodically complains of tingling
and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably
result from:

acetate accumulation

thiamine deficiency

triglyceride buildup

a below-normal serum potassium level

Question 7 Explanation:
Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which
results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and
excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional
deficiencies through diet and vitamin supplements, and preventing such residual disabilities
as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal
serum potassium level are unrelated to the client’s symptoms.

Question 8
WRONG
A female client with borderline personality disorder is admitted to the psychiatric unit. Initial
nursing assessment reveals that the client’s wrists are scratched from a recent suicide
attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of:

Ineffective individual coping related to

feelings of guilt

Situational low self-esteem related to

feelings of loss of control

Risk for violence: Self-directed related to

impulsive mutilating acts

Risk for violence: Directed toward others

related to verbal threats

Question 8 Explanation:
The predominant behavioral characteristic of the client with borderline personality disorder
is impulsiveness, especially of a physically self-destructive sort. The observation that the
client has scratched wrists doesn’t substantiate the other options.

Question 9
WRONG
A male client is being admitted to the substance abuse unit for alcohol detoxification. As
part of the intake interview, the nurse asks him when he had his last alcoholic drink. He
says that he had his last drink 6 hours before admission. Based on this response, nurse
Lorena should expect early withdrawal symptoms to:

begin after 7 days

not occur at all because the time period

for their occurrence has passed

begin anytime within the next 1 to 2

days
 begin within 2 to 7 days

Question 9 Explanation:
Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped
drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7
days — after the last drink.

Question 10
WRONG
Nurse Amy is aware that the client is at highest risk for suicide?

One who appears depressed, frequently

thinks of dying, and gives away all
personal possessions

One who plans a violent death and has

the means readily available

One who tells others that he or she

might do something if life doesn’t get
better soon

One who talks about wanting to die

Question 10 Explanation:
The client at highest risk for suicide is one who plans a violent death (for example, by
gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the
spouse leaves for work), and has the means readily available (for example, a rifle hidden in
the garage). A client who gives away possessions, thinks about death, or talks about
wanting to die or attempting suicide is considered at a lower risk for suicide because this
behavior typically serves to alert others that the client is contemplating suicide and wishes
to be helped.

Question 11
WRONG
Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic
acetaminophen (Tylenol) level?

deferoxamine mesylate (Desferal)

succimer (Chemet)
 flumazenil (Romazicon)

acetylcysteine (Mucomyst)

Question 11 Explanation:
The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic
metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron
intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative
effects of benzodiazepines.

Question 12
WRONG
A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best
nursing intervention at this time?

Keeping the client restrained in bed

Checking the client’s blood pressure

every 15 minutes and offering juices

Providing a quiet environment and

administering medication as needed and
prescribed

Restraining the client and measuring

blood pressure every 30 minutes

Question 12 Explanation:
Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to
reduce stimulation and administering prescribed central nervous system depressants in
dosages that control symptoms without causing oversedation. Although bed rest is
indicated, restraints are unnecessary unless the client poses a danger to himself or others.
Also, restraints may increase agitation and make the client feel trapped and helpless when
hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes
would interrupt the client’s rest. To avoid overstimulating the client, the nurse should check
blood pressure every 2 hours.

Question 13
WRONG
A male client has approached the nurse asking for advice on how to deal with his alcohol
addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is:

Psychotherapy
 total abstinence

Alcoholics Anonymous (AA)

aversion therapy

Question 13 Explanation:
Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance
at AA meetings, and aversion therapy are all adjunctive therapies that can support the client
in his efforts to abstain.

Question 14
WRONG
A male client is found sitting on the floor of the bathroom in the day treatment clinic with
moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at
her bleeding wrists while staff members call for an ambulance. How should Nurse
Anuktakanuk approach her initially?

Enter the room quietly and move beside

her to assess her injuries

Call for staff back-up before entering the

room and restraining her

Move as much glass away from her as

possible and sit next to her quietly

Approach her slowly while speaking in a

calm voice, calling her name, and telling
her that the nurse is here to help her

Question 14 Explanation:
Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the
nurse should approach the client cautiously while calling her name and talking to her in a
calm, confident manner. The nurse should keep in mind that the client shouldn’t be startled
or overwhelmed. After explaining that the nurse is there to help, the nurse should observe
the client’s response carefully. If the client shows signs of agitation or confusion or poses a
threat, the nurse should retreat and request assistance. The nurse shouldn’t attempt to sit
next to the client or examine injuries without first announcing the nurse’s presence and
assessing the dangers of the situation.

Question 15
WRONG
A male client recently admitted to the hospital with sharp, substernal chest pain suddenly
complains of palpitations. Nurse Ryan notes a rise in the client’s arterial blood pressure and
a heart rate of 144 beats/minute. On further questioning, the client admits to having used
cocaine recently after previously denying use of the drug. The nurse concludes that the
client is at high risk for which complication of cocaine use?

Coronary artery spasm

Bradyarrhythmias

Neurobehavioral deficits

Panic disorder

Question 15 Explanation:
Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial
infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death.
Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess
of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more
likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits
are common in neonates born to cocaine users, they are rare in adults. As craving for the
drug increases, a person who’s addicted to cocaine typically experiences euphoria followed
by depression, not panic disorder

Question 16
WRONG
Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is
necessary. Which intervention is also important?

Fill out the client’s menu and make sure

she eats at least half of what is on her
tray.

Let the client eat her meals in private.

Then engage her in social activities for at
least 2 hours after each meal

Let the client choose her own food. If

she eats everything she orders, then stay
with her for 1 hour after each meal

Let the client eat food brought in by the

family if she chooses, but she should
keep a strict calorie count.

Question 16 Explanation:
Allowing the client to select her own food from the menu will help her feel some sense of
control. She must then eat 100% of what she selected. Remaining with the client for at least
1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food
provided by the dietary department.

Question 17
WRONG
When interviewing the parents of an injured child, which of the following is the strongest
indicator that child abuse may be a problem?

The injury isn’t consistent with the

history or the child’s age

The mother and father tell different

stories regarding what happened

The family is poor

The parents are argumentative and

demanding with emergency department
personnel

Question 17 Explanation:
When the child’s injuries are inconsistent with the history given or impossible because of the
child’s age and developmental stage, the emergency department nurse should be
suspicious that child abuse is occurring. The parents may tell different stories because their
perception may be different regarding what happened. If they change their story when
different health care workers ask the same question, this is a clue that child abuse may be a
problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be
demanding because of the stress of having an injured child.

Question 18
WRONG
Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to
his early teenage years, includes delinquency, running away, auto theft, and vandalism. He
dropped out of school at age 16 and has been living on his own since then. His history
suggests maladaptive coping, which is associated with:

antisocial personality disorder

borderline personality disorder

obsessive-compulsive personality
disorder
 narcissistic personality disorder

Question 18 Explanation:
The client’s history of delinquency, running away from home, vandalism, and dropping out
of school are characteristic of antisocial personality disorder. This maladaptive coping
pattern is manifested by a disregard for societal norms of behavior and an inability to relate
meaningfully to others. In borderline personality disorder, the client exhibits mood instability,
poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality
disorder is characterized by a preoccupation with impulses and thoughts that the client
realizes are senseless but can’t control. Narcissistic personality disorder is marked by a
pattern of self-involvement, grandiosity, and demand for constant attention.

Question 19
WRONG
Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with
disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on
which of the following products?

Carbonated beverages

Aftershave lotion

Toothpaste

Cheese

Question 19 Explanation:
Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse
drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of
acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences
noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a
reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to
avoid products containing alcohol such as aftershave lotions. Carbonated beverages,
toothpaste, and cheese don’t contain alcohol and don’t need to be avoided by the client.

Question 20
WRONG
A male client admitted to the psychiatric unit for treatment of substance abuse says to the
nurse, “It felt so wonderful to get high.” Which of the following is the most appropriate
response?

“If you continue to talk like that, I’m

going to stop speaking to you.”
 “You told me you got fired from your last
job for missing too many days after
taking drugs all night.”

“Tell me more about how it felt to get

high.”

“Don’t you know it’s illegal to use

drugs?”

Question 20 Explanation:
Confronting the client with the consequences of substance abuse helps to break through
denial. Making threats (option A) isn’t an effective way to promote self-disclosure or
establish a rapport with the client. Although the nurse should encourage the client to
discuss feelings, the discussion should focus on how the client felt before, not during, an
episode of substance abuse (option C). Encouraging elaboration about his experience while
getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug
use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

Question 21
WRONG
The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with
oppositional defiant disorder?

Accept responsibility for own behaviors

Be able to verbalize own needs and

assert rights

Set firm and consistent limits with the

client

Allow the child to establish his own limits

and boundaries

Question 21 Explanation:
Children with oppositional defiant disorder frequently violate the rights of others. They are
defiant, disobedient, and blame others for their actions. Accountability for their actions
would demonstrate progress for the oppositional child. Options C and D aren’t outcome
criteria but interventions. Option B is incorrect as the oppositional child usually focuses on
his own needs.

Question 22
 WRONG
Eighteen hours after undergoing an emergency appendectomy, a client with a reported
history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart
rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm
Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in
the bed. Nurse Melinda should suspect:

a postoperative infection

alcohol withdrawal

acute sepsis

pneumonia

Question 22 Explanation:
The client’s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal
syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative
complications, they wouldn’t cause this client’s signs and symptoms and typically would
occur later in the postoperative course

Question 23
WRONG
During postprandial monitoring, a female client with bulimia nervosa tells the nurse, “You
can sit with me, but you’re just wasting your time. After you sat with me yesterday, I was still
able to purge. Today, my goal is to do it twice.” What is the nurse’s best response?

“I trust you not to purge.”

“How are you purging and when do you

do it?”

“Don’t worry. I won’t allow you to purge

today.”

“I know it’s important for you to feel in

control, but I’ll monitor you for 90
minutes after you eat.”

Question 23 Explanation:
This response acknowledges that the client is testing limits and that the nurse is setting
them by performing postprandial monitoring to prevent self-induced emesis. Clients with
bulimia nervosa need to feel in control of the diet because they feel they lack control over all
other aspects of their lives. Because their therapeutic relationships with caregivers are less
important than their need to purge, they don’t fear betraying the nurse’s trust by engaging in
the activity. They commonly plot purging and rarely share their secrets about it. An
authoritarian or challenging response may trigger a power struggle between the nurse and
client.

Question 24
WRONG
A parent brings a preschooler to the emergency department for treatment of a dislocated
shoulder, which allegedly happened when the child fell down the stairs. Which action should
make the nurse suspect that the child was abused?

The child cries uncontrollably throughout

the examination.

The child pulls away from contact with

the physician.

The child doesn’t cry when the shoulder

is examined.

The child doesn’t make eye contact with

the nurse.

Question 24 Explanation:
A characteristic behavior of abused children is lack of crying when they undergo a painful
procedure or are examined by a health care professional. Therefore, the nurse should
suspect child abuse. Crying throughout the examination, pulling away from the physician,
and not making eye contact with the nurse are normal behaviors for preschoolers.

Question 25
WRONG
A male client tells the nurse he was involved in a car accident while he was intoxicated.
What would be the most therapeutic response from nurse Julia?

“Why didn’t you get someone else to

drive you?”

“Tell me how you feel about the

accident.”

“You should know better than to drink

and drive.”

“I recommend that you attend an

Alcoholics Anonymous meeting.”
Question 25 Explanation:
An open-ended statement or question is the most therapeutic response. It encourages the
widest range of client responses, makes the client an active participant in the conversation,
and shows the client that the nurse is interested in his feelings. Asking the client why he
drove while intoxicated can make him feel defensive and intimidated. A judgmental
approach isn’t therapeutic. By giving advice, the nurse suggests that the client isn’t capable
of making decisions, thus fostering dependency.

Question 26
WRONG
A male client is being treated for alcoholism. After a family meeting, the client’s spouse asks
the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily
should suggest that the family join which organization?

Al-Anon

Make Today Count

Emotions Anonymous

Alcoholics Anonymous

Question 26 Explanation:
Al-Anon is an organization that assists family members to share common experiences and
increase their understanding of alcoholism. Make Today Count is a support group for
people with life-threatening or chronic illnesses. Emotions Anonymous is a support group
for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is
an organization that helps alcoholics recovers by using a twelve-step program.

Question 27
WRONG
Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal
for a client diagnosed with bulimia is to:

avoid shopping for large amounts of

food

control eating impulses

identify anxiety-causing situations

eat only three meals per day

Question 27 Explanation:
Bulimic behavior is generally a maladaptive coping response to stress and underlying
issues. The client must identify anxiety-causing situations that stimulate the bulimic
behavior and then learn new ways of coping with the anxiety. Controlling shopping for large
amounts of food isn’t a goal early in treatment. Managing eating impulses and replacing
them with adaptive coping mechanisms can be integrated into the plan of care after initially
addressing stress and underlying issues. Eating three meals per day isn’t a realistic goal
early in treatment.

Question 28
WRONG
A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the
following medications is Nurse Alice most likely to administer to reduce the symptoms of
alcohol withdrawal?

naloxone (Narcan)

haloperidol (Haldol)

magnesium sulfate

chlordiazepoxide (Librium)

Question 28 Explanation:
Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol
withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe
agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium
sulfate and other anticonvulsant medications are only administered to treat seizures if they
occur during withdrawal.

Question 29
WRONG
A 25 –year old client experiencing alcohol withdrawal is upset about going through
detoxification. Which of the following goals is a priority?

The client will commit to a drug-free

lifestyle

The client will work with the nurse to

remain safe

The client will drink plenty of fluids daily

 The client will make a personal inventory
of strength

Question 29 Explanation:
The priority goal in alcohol withdrawal is maintaining the client’s safety. Committing to a
drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important
goals, but ensuring the client’s safety is the nurse’s top priority.

Question 30
WRONG
Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse’s highest
care priority?

Assessing the client’s home environment

and relationships outside the hospital

Exploring the nurse’s own feelings about

suicide

Discussing the future with the client

Referring the client to a clergyperson to

discuss the moral implications of suicide

Question 30 Explanation:
The nurse’s values, beliefs, and attitudes toward self-destructive behavior influence
responses to a suicidal client; such responses set the overall mood for the nurse-client
relationship. Therefore, the nurse initially must explore personal feelings about suicide to
avoid conveying negative feelings to the client. Assessment of the client’s home
environment and relationships may reveal the need for family therapy; however, conducting
such an assessment isn’t a nursing priority. Discussing the future and providing anticipatory
guidance can help the client prepare for future stress, but this isn’t a priority. Referring the
client to a clergyperson may increase the client’s trust or alleviate guilt; however, it isn’t the
highest priority.

Question 31
WRONG
For a female client with anorexia nervosa, nurse Rose plans to include the parents in
therapy sessions along with the client. What fact should the nurse remember to be typical of
parents of clients with anorexia nervosa?

They tend to overprotect their children

 They usually have a history of substance
abuse

They maintain emotional distance from

their children

They alternate between loving and

rejecting their children

Question 31 Explanation:
Clients with anorexia nervosa typically come from a family with parents who are controlling
and overprotective. These clients use eating to gain control of an aspect of their lives. The
characteristics described in options B, C, and D isn’t typical of parents of children with
anorexia.

Question 32
WRONG
A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring
for her realizes that this exacerbation of anorexia nervosa results from the client’s effort to:

manipulate her husband

gain control of one part of her life

commit suicide

live up to her mother’s expectations

Question 32 Explanation:
By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control
over the only part of her life she feels she can control. This eating disorder doesn’t
represent an attempt to manipulate others or live up to their expectations (although anorexia
nervosa has a high incidence in families that emphasize achievement). The client isn’t
attempting to commit suicide through starvation; rather, by refusing to eat, she is expressing
feelings of despair, worthlessness, and hopelessness.

Question 33
WRONG
Flumazenil (Romazicon) has been ordered for a male client who has overdosed on
oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for
which common adverse effect?
 Seizures

Shivering

Anxiety

Chest pain

Question 33 Explanation:
Seizures are the most common serious adverse effect of using flumazenil to reverse
benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic
antidepressant and benzodiazepine overdose. Less common adverse effects include
shivering, anxiety, and chest pain.

Question 34
WRONG
Nurse Taylor is aware that the victims of domestic violence should be assessed for what
important information?

Reasons they stay in the abusive

relationship (for example, lack of
financial autonomy and isolation)

Readiness to leave the perpetrator and

knowledge of resources

Use of drugs or alcohol

History of previous victimization

Question 34 Explanation:
Victims of domestic violence must be assessed for their readiness to leave the perpetrator
and their knowledge of the resources available to them. Nurses can then provide the victims
with information and options to enable them to leave when they are ready. The reasons
they stay in the relationship are complex and can be explored at a later time. The use of
drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization
results in a person’s seeking or causing abusive relationships.

Question 35
WRONG
For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the
highest priority?
 The client will establish adequate daily
nutritional intake

The client will make a contract with the

nurse that sets a target weight

The client will identify self-perceptions

about body size as unrealistic

The client will verbalize the possible

physiological consequences of self-
starvation

Question 35 Explanation:
According to Maslow’s hierarchy of needs, all humans need to meet basic physiological
needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first
plan to help the client meet this basic, immediate physiological need. The nurse may give
lesser priority to goals that address long-term plans (as in option B), self-perception (as in
option C), and potential complications (as in option D).

Question 36
WRONG
Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing
intervention is most appropriate for this client?

Providing one-on-one supervision during

meals and for 1 hour afterward

Letting the client eat with other clients

to create a normal mealtime atmosphere

Trying to persuade the client to eat and

thus restore nutritional balance

Giving the client as much time to eat as

desired

Question 36 Explanation:
Because the client with anorexia nervosa may discard food or induce vomiting in the
bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour
afterward. Option B wouldn’t be therapeutic because other clients may urge the client to eat
and give attention for not eating. Option C would reinforce control issues, which are central
to this client’s underlying psychological problem. Instead of giving the client unlimited time
to eat, as in option D, the nurse should set limits and let the client know what is expected.
Question 37
WRONG
When monitoring a female client recently admitted for treatment of cocaine addiction, nurse
Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct
these problems, the nurse expects the physician to prescribe:

norepinephrine (Levophed) and

lidocaine (Xylocaine)

nifedipine (Procardia) and lidocaine

nitroglycerin (Nitro-Bid IV) and esmolol

(Brevibloc)

nifedipine and esmolol

Question 37 Explanation:
This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-
adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an antiarrhythmic,
isn’t indicated because the client doesn’t have an arrhythmia. Although nitroglycerin may be
used to treat coronary vasospasm, it isn’t the drug of choice in hypertension.

Question 38
WRONG
A female client who’s at high risk for suicide needs close supervision. To best ensure the
client’s safety, Nurse Mary should:

check the client frequently at irregular

intervals throughout the night

assure the client that the nurse will hold

in confidence anything the client says

repeatedly discuss previous suicide

attempts with the client

disregard decreased communication by

the client because this is common in
suicidal clients

Question 38 Explanation:
Checking the client frequently but at irregular intervals prevents the client from predicting
when observation will take place and altering behavior in a misleading way at these times.
Option B may encourage the client to try to manipulate the nurse or seek attention for
having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased
communication is a sign of withdrawal that may indicate the client has decided to commit
suicide; the nurse shouldn’t disregard it (option D)

Question 39
WRONG
Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action
should the nurse include in the plan?

Restrict visits with the family until the

client begins to eat

Provide privacy during meals

Set up a strict eating plan for the client

Encourage the client to exercise, which

will reduce her anxiety

Question 39 Explanation:
Establishing a consistent eating plan and monitoring the client’s weight are important for this
disorder. The family should be included in the client’s care. The client should be monitored
during meals — not given privacy. Exercise must be limited and supervised.

Question 40
WRONG
A male client with a history of cocaine addiction is admitted to the coronary care unit for
evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-
segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5.
Considering the client’s history of drug abuse, nurse Greg expects the physician to
prescribe:

lidocaine (Xylocaine)

procainamide (Pronestyl)

nitroglycerin (Nitro-Bid IV)

epinephrine

Question 40 Explanation:
The elevated ST segments in this client’s ECG indicate myocardial ischemia. To reverse
this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the
coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for
this client at some point but aren’t used for coronary artery dilation. If a cocaine user
experiences ventricular fibrillation or asystole, the physician may prescribe epinephrine.
However, this drug must be used with caution because cocaine may potentiate its
adrenergic effects.

Question 41
WRONG
A male client is admitted to a psychiatric facility by court order for evaluation for antisocial
personality disorder. This client has a long history of initiating fights and abusing animals
and recently was arrested for setting a neighbor’s dog on fire. When evaluating this client
for the potential for violence, nurse Perry should assess for which behavioral clues?

A rigid posture, restlessness, and glaring

Depression and physical withdrawal

Silence and noncompliance

Hypervigilance and talk of past violent

acts

Question 41 Explanation:
Behavioral clues that suggest the potential for violence include a rigid posture, restlessness,
glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical
withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug
use, talk of past violent acts, inability to express feelings, repetitive demands and
complaints, argumentativeness, profanity, disorientation, inability to focus attention,
hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent
clients rarely exhibit depression, silence, or hypervigilance.

Question 42
WRONG
Nurse Fey is aware that the drug of choice for treating Tourette syndrome?

fluoxetine (Prozac)

fluvoxamine (Luvox)

haloperidol (Haldol)

paroxetine (Paxil)

Question 42 Explanation:
Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil
are antidepressants and aren’t used to treat Tourette syndrome

Question 43
WRONG
A 14-year-old client is brought to the clinic by her mother. Her mother expresses concern
about her daughter’s weight loss and constant dieting. Nurse Kris conducts a health history
interview. Which of the following comments indicates that the client may be suffering from
anorexia nervosa?

“I like the way I look. I just need to keep

my weight down because I’m a
cheerleader.”

“I don’t like the food my mother cooks. I

eat plenty of fast food when I’m out with
my friends.”

“I just can’t seem to get down to the

weight I want to be. I’m so fat compared
to other girls.”

“I do diet around my periods; otherwise,

I just get so bloated.”

Question 43 Explanation:
Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down
to a “desirable weight” is characteristic of the disorder. Feeling inadequate when compared
to peers indicates poor self-esteem. Most clients with anorexia nervosa don’t like the way
they look, and their self-perception may be distorted. A girl with cachexia may perceive
herself to be overweight when she looks in the mirror. Preferring fast food over healthy food
is common in this age-group. Because of the absence of body fat necessary for proper
hormone production, amenorrhea is common in a client with anorexia nervosa.

Question 44
WRONG
A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol
detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to
prescribe which drug?

clozapine (Clozaril)

thiothixene (Navane)
 lorazepam (Ativan)

lithium carbonate (Eskalith)

Question 44 Explanation:
The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a
benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate
is an antimanic agent; these drugs aren’t used to manage alcohol withdrawal syndrome.

Question 45
WRONG
Nurse Penny is aware that the following medical conditions is commonly found in clients
with bulimia nervosa?

Allergies

Cancer

Diabetes mellitus

Hepatitis A

Question 45 Explanation:
Bulimia nervosa can lead to many complications, including diabetes, heart disease, and
hypertension. The eating disorder isn’t typically associated with allergies, cancer, or
hepatitis A.

Question 46
WRONG
Kellan, a high school student is referred to the school nurse for suspected substance abuse.
Following the nurse’s assessment and interventions, what would be the most desirable
outcome?

The student discusses conflicts over drug

use

The student accepts a referral to a

substance abuse counselor

The student agrees to inform his parents

of the problem
 The student reports increased comfort
with making choice

Question 46 Explanation:
All of the outcomes stated are desirable; however, the best outcome is that the student
would agree to seek the assistance of a professional substance abuse counselor

Question 47
WRONG
Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly
the night before. The husband indicates that his childhood was marred by an abusive
relationship with his father. When intervening with this couple, nurse Gerry knows they are
at risk for repeated violence because the husband:

has only moderate impulse control

denies feelings of jealousy or

possessiveness

has learned violence as an acceptable

behavior

feels secure in his relationship with his

wife

Question 47 Explanation:
Family violence usually is a learned behavior, and violence typically leads to further
violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate,
impulse control. Violent people commonly are jealous and possessive and feel insecure in
their relationships

Question 48
WRONG
When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is
aware that the following is the highest priority?

Client’s physical needs

Client’s safety needs

Client’s psychosocial needs

 Client’s medical needs

Question 48 Explanation:
The highest priority for a client who has ingested PCP is meeting safety needs of the client
as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose
control easily. After safety needs have been met, the client’s physical, psychosocial, and
medical needs can be met.

Question 49
WRONG
Nurse Bella is aware that assessment finding is most consistent with early alcohol
withdrawal?

Heart rate of 120 to 140 beats/minute

Heart rate of 50 to 60 beats/minute

Blood pressure of 100/70 mm Hg

Blood pressure of 140/80 mm Hg

Question 49 Explanation:
Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol
withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different
stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during
the early withdrawal stages, may occur in later stages. Hypotension is associated with
cardiovascular collapse and most commonly occurs in clients who don’t receive treatment.
The nurse should monitor the client’s vital signs carefully throughout the entire alcohol
withdrawal process.

Question 50
WRONG
A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To
promote the client’s physical health, nurse Tair should plan to:

severely restrict the client’s physical

activities

weigh the client daily, after the evening

meal
 monitor vital signs, serum electrolyte
levels, and acid-base balance

instruct the client to keep an accurate

record of food and fluid intake

Question 50 Explanation:
An anorexic client who requires hospitalization is in poor physical condition from starvation
and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac
abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client’s vital
signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen
anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate
than one obtained after the evening meal. Option D would reward the client with attention
for not eating and reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and fluid intake inaccurately.