1. Nurse Tim is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

a. Avoid shopping for large amounts of food b. Control eating impulses c. Identify anxiety-causing situations d. Eat only three meals per day

Answer C. 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.

2. For a female client with anorexia nervosa, the nurse is aware that which goal takes the highest priority?

a. The client will establish adequate daily nutritional intake b. The client will make a contract with the nurse that sets a target weight c. The client will identify self-perceptions about body size as unrealistic d. The client will verbalize the possible physiological consequences of self-starvation

Answer A. 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.

3. A female client who’s at high risk for suicide needs close supervision. To best ensure the client’s safety, the nurse should:

a. Check the client frequently at irregular intervals throughout the night b. Assure the client that the nurse will hold in confidence anything the client says c. Repeatedly discuss previous suicide attempts with the client d. Disregard decreased communication by the client because this is common in suicidal clients

Answer A. 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.

4. A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first?

a. Request psychiatric consultation b. Complete a thorough physical assessment including lab tests c. Remove all hazardous materials from the environment d. Place the client on a one to one observation.

Answer B. Numerous physical condition can contribute to symptoms of insomnia, including irritability, anorexia, and depressed mood. It is important for the nurse to rule out these physical problems before assuming that the symptoms are psychological in nature. The nurse can do this by completing a thorough physical assessments including lab tests.

5. A nurse is assessing a client in the mental health clinic. The client has a long history of being a loner and has few social relationships. This client’s father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase in the development of schizophrenia?

a. Schizoid personality b. Prodromal phase c. Schizophrenia d. Residual phase

Answer A. Individuals diagnosed with schizoid personality disorder are typically loners who appear cold and aloof and are indifferent to social relationships. Not all individual who demonstrate the characteristics of schizoid personality progress to schizophrenia, but because of a family history of schizophrenia, this client’s risk for acquiring the disease increases from 1% to 10%.

6. A client on an in-patient psychiatric unit refused to take medications because. “the pill has a special code written on it that will make it poisonous.” What kid of delusion is this client experiencing?

a. An erotomanic delusion b. A grandiose delusion c. A persecutory delusion d. A somatic delusion

Answer C. A persecutory delusion is a type of delusion in which the individual believes he or she is being malevolently treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, harassed, or obstructed in the pursuit of long-term goals.

7. 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? a. “If you continue to talk like that, I’m going to stop speaking to you.” b. “You told me you got fired from your last job for missing too many days after taking drugs all night.” c. “Tell me more about how it felt to get high.” d. “Don’t you know it’s illegal to use drugs?”

Answer B. 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.

8. A client brought to the emergency department is observed to be sweating, has dilated pupils, and complains of muscle aches and abdominal cramping. A toxicology screen is ordered. The nurse would suspect these symptoms are indicative of withdrawal from which substances.

a. Heroin b. Methaphetamine c. Fluitrazepam (Rohypnol) d. Alcohol

Answer A. Heroin is an opioid derivative. Symptoms of heroin withdrawal include dilated pupils, muscle aches, diarrhea, and nausea and vomiting. Other symptoms are rhinorrhea, sweating, yawning, fever and insomnia.

9. 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. A postoperative infection b. Alcohol withdrawal c. Acute sepsis. d. Pneumonia.

Answer B. 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

10. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority?

a. Calmly redirect and remove the client from the milieu b. Administer prescribed PRN intramuscular injection for agitation c. Notify the client to lower voice d. Obtain an order for seclusion to help decrease external stimuli

Answer A. When a client experiencing mania is yelling at other peers, it is the nurse’s priority to address this situation immediately. Behaviors of this type can escalate into violence toward client and staff members. By sing a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit.