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    Exam Review

    1. A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
      A)
      Wrap the blood pressure cuff snugly around the arm.
      B)
      Center the cuff bladder over the brachial artery.
      C)
      Place the client's arm above the level of the heart.
      D)
      Check the instrument gauge to ensure the reading starts at zero
    2. If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)
      A)
      pulse deficit
      B)
      diastolic
      C)
      auscultatory gap
      D)
      widened pulse pressure
    3. A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
      A)
      check the patient's record to determine his baseline blood pressure.
      B)
      notify the charge nurse of the hypotension.
      C)
      check medications that might be the cause of the irregularity.
      D)
      notify the doctor of the bradycardia.
    4. A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect?
      A)
      Unable to identify with the feelings of others.
      B)
      Views self as inferior to others.
      C)
      Manipulates others for personal gain.
      D)
      Uses physical appearance to gain attention.
    Page 1 of 9

    Exam Review

    1. A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?
      A)
      The client is hostile and sarcastic towards the staff.
      B)
      The client paces in the hallway during the day and most of the night.
      C)
      The client gives money away to other clients.
      D)
      The client demonstrates flight of ideas once a week but is more quiet during meals
    2. A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)
      (SATA)
      A)
      Impaired gait
      B)
      Fidgeting behavior
      C)
      Muscle contractions of the neck
      D)
      Fluctuating vital signs
      E)
      Sexual dysfunction
    3. A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
      A)
      Telling his parents that he doesn't want to talk about the attempt
      B)
      Planning to give his CD collection to his girlfriend
      C)
      Stating that he wants to be with his peers more than with his parents
      D)
      Preferring to eat his meals while watching TV
    4. A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?
      A)
      Medication compliance
      B)
      Awareness of potential for self-harm
      C)
      Resources for group therapy in the community
      D)
      Information about insurance coverage
    Page 2 of 9

    Exam Review

    1. A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:2 tablets
    2. A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?
      A)
      Schizoid personality disorder
      B)
      Dependent personality disorder
      C)
      Avoidant personality disorder
      D)
      Antisocial personality disorder
    3. A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?
      A)
      The client will identify positive qualities about herself.
      B)
      The client will contact a staff member when she feels she might hurt herself.
      C)
      The client will identify ways to achieve a reachable goal for the future.
      D)
      The client will identify her position in the grief process.
    4. A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?
      A)
      "Why are you not seeing the value of this treatment plan for recovery?"
      B)
      "You may want to consider moving to a group home, since you will not be free of the troublesome symptoms."
      C)
      "While you may not be completely symptom-free, you should still see an increase in your quality of life by continuing with the treatment plan."
      D)
      "The medical model of recovery works to eliminate all symptoms. Maybe you should see a medical doctor."
    Page 3 of 9

    Exam Review

    1. A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?
      A)
      "You really should work hard to stay on the schedule we establish here."
      B)
      "I wouldn't worry about what you've done in the past. You'll do just fine this time."
      C)
      "Why do you find it difficult to take your medications if they improve your condition?"
      D)
      "Let's work together to devise a schedule that is convenient for you on a daily basis."
    2. A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?
      A)
      "Go back to your room, and I'll try to get in touch with your provider in the morning."
      B)
      "Everything will be okay until morning. You can speak with your provider then."
      C)
      "Why don't you wait to speak to your provider in the morning?"
      D)
      "You seem to be very upset about something. Tell me about it."
    3. A nurse is preparing to administer diphenhydramine 35 mg IM to a client who has schizophrenia. Available is diphenhydramine for injection 50 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    4. The nurse is teaching the family of a client about the signs and symptoms of major depression prior to the discharge of their loved one from an inpatient stay after a suicide attempt. Which statement by a family member warrants further education by the nurse?
      A)
      I will encourage him to join me in a daily walk with the dog to the park on the corner.
      B)
      I will set timers for his medications and meals
      C)
      I will let him have his freedom and wont ask any questions. This is his life not mine.
      D)
      Engage with him daily on how he is feeling and what he goals he has set for the day.
    Page 4 of 9

    Exam Review

    1. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following findings should the nurse expect?
      A)
      Requiring frequent reassurance from others
      B)
      Lack of feelings of remorse
      C)
      Inflated sense of self
      D)
      Suspiciousness of others
    2. A nurse must be alert when a client is giving away possessions, getting his/her life in order, or making vague goodbyes to people. Which of the following should the nurse be concerned about?
      A)
      Depressive State
      B)
      Suicidal intent
      C)
      A plan to relocate
      D)
      Elopement with partner
    3. A nurse in an acute mental health unit is assisting with the admission of a client who has bipolar disorder. Which of the following findings indicates that the client is experiencing acute mania?
      A)
      The client responds to questions with disorganized speech.
      B)
      The client reports that voices are telling him to write a novel.
      C)
      The client is dressed in all black.
      D)
      The client's partner reports that the client has recently gained weight.
    4. A nurse on a mental health unit is caring for a client who refuses to follow instructions and states that the unit rules do not apply to them. The nurse should identify that these findings are manifestations of which of the following personality disorders?
      A)
      Antisocial personality disorder
      B)
      Schizotypal personality disorder
      C)
      Histrionic personality disorder
      D)
      Narcissistic personality disorder
    Page 5 of 9

    Exam Review

    1. A nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?
      A)
      "The voices are part of your illness."
      B)
      "I know you hear the voices, but I do not."
      C)
      "How often do you hear the voices?"
      D)
      "What are the voices telling you?"
    2. A nurse is collecting data from a client who has schizophrenia and has been taking chlorpromazine for 8 years. The nurse notes choreiform or jerking uncontrolled movements, lip smacking, and spastic facial distortions. Which of the following conditions should the nurse document in her finding?
      A)
      Tardive dyskinesia
      B)
      Lock Jaw (unable to close mouth)
      C)
      Pseudoparkinsonism
      D)
      Akathisia
    3. A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?
      A)
      Preoccupied with maintaining order by following rigid rules
      B)
      Believes his achievements are superior to others
      C)
      Requires excessive amount of advice before making decisions
      D)
      Uses physical appearance to make others take notice of him
    4. A nurse is preparing to administer buspirone 25 mg PO. Available is buspirone 10 mg scored tablets. How many tablets should the nurse plan to administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    Page 6 of 9