Question 1

Which quality is essential for a nurse to be an effective spiritual care provider?

Accepted Answer

Answer reason: Effective spiritual care requires the nurse to recognize personal values, beliefs, and biases so they do not shape or limit the patient’s spiritual expression. By being aware of their own worldview, the nurse can maintain therapeutic boundaries and provide nonjudgmental, patient-centered support. This enables appropriate use of open-ended questions, active listening, and timely referral (e.g., chaplain) based on the patient’s preferences. Other traits like patience or motivation can help rapport, but without insight into one’s own beliefs, the nurse is more likely to impose meaning or miss cues, reducing the quality of spiritual support.

Question 2

f Which percentage of those with mental illness receive treatment in the health care system?

Accepted Answer

Answer reason: A core public-health mental health concept is that a substantial proportion of people with mental illness do not receive any formal care because of access barriers, stigma, cost, and lack of available services. The commonly taught statistic in nursing review materials is that only about two-fifths of individuals with mental illness receive treatment within the health care system. The other options underestimate or overestimate typical treatment engagement rates and do not align with this widely cited benchmark. Knowing this gap supports nursing advocacy, screening, and referral efforts to improve access to mental health care.

Question 3

Which nursing diagnosis is most appropriate for a client with sexual masochism?

Accepted Answer

Answer reason: The most immediate nursing concern is safety, specifically the potential for self-inflicted tissue damage during these behaviors. This makes a risk diagnosis focused on self-harm the best match among the options. “Risk for other-directed violence” does not align because the defining feature is receiving pain rather than inflicting it, and the other options are too nonspecific compared with the direct injury risk.

Question 4

What is the gender identity disorder that results in the person believing he or she is the opposite sex?

Accepted Answer

Answer reason: This option best matches that core concept. Exhibitionism is a paraphilic disorder involving exposing one’s genitals to unsuspecting people, not identity incongruence. Transvestitism refers to cross-dressing (often for sexual arousal) without a fixed belief of being the other sex, and homosexuality describes sexual orientation rather than gender identity.

Question 5

The nurse is caring for a client who conceals the true motivations for his thoughts, actions, or feelings. The nurse interprets this as?

Accepted Answer

Answer reason: Rationalization is a defense mechanism in which a person offers plausible-sounding explanations to mask the real, often anxiety-provoking, reasons for behaviors or feelings. Concealing the true motivations while presenting an acceptable justification fits this mechanism directly. In contrast, displacement involves shifting emotions from a threatening target to a safer one, and regression is reverting to earlier developmental behaviors under stress. Substitution is not the best match for hiding motives; the defining feature here is explaining away or justifying to avoid the true reason.

Question 6

Which nursing diagnosis is most appropriate for a client with somatoform pain disorder?

Accepted Answer

Answer reason: The most appropriate nursing focus is on helping the client identify stressors, build adaptive coping strategies, and reduce reinforcement of the sick role while validating the pain experience. This diagnosis supports interventions such as stress management, problem-solving, and therapeutic communication aimed at improving function and reducing symptom-driven behaviors. Other options may occur secondarily (e.g., family strain), but they do not capture the core, treatable mechanism most directly targeted by nursing care.

Question 7

In order to be effective, nursing interventions should consider the client’s wholeness. The human self-concept is a major concern for all nurses and comprises attitudes about?

Accepted Answer

Answer reason: Self-concept refers to an individual’s perceptions, beliefs, and feelings about their own identity, worth, abilities, and roles. Nursing care that addresses wholeness includes assessing how illness or stress affects a client’s body image, self-esteem, and role performance, all of which are internal attitudes. The other options describe attitudes toward other people or relationships, which may influence coping but are not the definition of self-concept. Recognizing disrupted self-concept guides therapeutic communication and appropriate psychosocial support interventions.

Question 8

Which religion worships Allah, performs ritual prayers five times per day with ablutions prior, and attends mosque or gathers with groups at noon on Fridays?

Accepted Answer

Answer reason: The key principle is culturally competent care: nurses should recognize core religious practices that can affect scheduling, hygiene, diet, and privacy needs. The description matches the five daily prayers (salat) with ritual washing (wudu) performed beforehand and the congregational Friday noon prayer (Jumu'ah) typically held at a mosque. Knowing this helps anticipate requests for time/space to pray and access to water for ablutions without disrupting treatment. The other listed religions do not have a required five-times-daily prayer pattern tied to ablutions and Friday congregational mosque prayer.

Question 9

Which religion believes that physical disease results from good or bad karma (result of acts previously committed)?

Accepted Answer

Answer reason: The core concept is cultural/religious beliefs that can shape a patient’s explanatory model of illness and influence coping and care decisions. Hindu traditions commonly include karma as a moral law of cause-and-effect across actions, and illness may be interpreted as related to past actions. This makes it the best match to the question’s framing of disease resulting from good or bad karma. In contrast, Catholicism and Judaism do not center illness causation on karma as a doctrinal explanation in the same way, so they are less consistent with the stem.

Question 10

A nursing student is learning about suicide by poisoning in nursing school. The student knows that the group most likely to commit suicide by poisoning is?

Accepted Answer

Answer reason: Suicide method patterns differ by sex: females more commonly use self-poisoning/overdose, while males more commonly use highly lethal violent means such as firearms. Overdose is often more accessible and may be chosen in contexts involving medications and substances in the home. Therefore, the group most likely to commit suicide by poisoning is females. A common distractor is males, who have higher overall suicide completion rates but typically with different methods.

Question 11

A client with borderline personality disorder has extreme views of himself and his situation. Which behavior indicates that the client is a candidate for medication?

Accepted Answer

Answer reason: Marked mood swings suggest clinically significant affective dysregulation that may respond to pharmacologic support (e.g., mood stabilizers or certain atypical antipsychotics) alongside psychotherapy. Disorientation points more toward delirium, intoxication, or neurologic disease and requires medical evaluation rather than routine BPD-focused medication. Hyperactivity and regression are not core medication-target symptoms in BPD and are more commonly managed with behavioral/psychotherapeutic approaches and assessment for alternative diagnoses.

Question 12

The client reports becoming involved with legislation that promotes gun safety after the death of the child by accidental shooting. Which defense mechanism is the client exhibiting?

Accepted Answer

Answer reason: After a traumatic loss, engaging in advocacy and policy work redirects grief and potential anger into meaningful prevention efforts. This adaptive channeling helps the client cope while potentially benefiting others. Denial would involve refusing to acknowledge the reality of the death, while intellectualization would focus on detached facts and analysis rather than purposeful action.

Question 13

The nurse anticipates that which of the following is a major stressor for a couple being treated for infertility?

Accepted Answer

Answer reason: This disruption often affects relationship satisfaction, self-esteem, and sexual functioning, making it a major and persistent stressor during evaluation and treatment. Compared with episodic discomforts like exams or specimen collection, timed intercourse repeatedly intrudes on daily life and couple dynamics. While learning which partner has infertility can be emotionally painful, the ongoing requirement to plan sex around fertility windows is a frequent, day-to-day stressor.

Question 14

A nurse is caring for several clients with gender identity disorders. Which client category is at highest risk for anxiety related to transsexualism?

Accepted Answer

Answer reason: Stigma, bullying, and fear of rejection commonly escalate worry, avoidance, and mood symptoms in this age group, increasing clinical anxiety risk. The onset or worsening of dysphoria around puberty can make symptoms more acute than in prepubescent children, who may have less body-related distress prior to pubertal changes. Older adults and many young adults may have more developed coping strategies or established support systems compared with adolescents navigating rapid developmental transitions.

Question 15

A client with sleep terror disorder might have autonomic signs of intense anxiety. It is most important for the nurse to assess the client for which of the following?

Accepted Answer

Answer reason: A key autonomic manifestation of this intense anxiety response is increased heart rate, which is also clinically important because it helps gauge physiologic severity and immediate risk. Pupillary constriction and decreased muscle tone are not typical sympathetic “fight-or-flight” findings, making them poor indicators of this state. Cool, clammy skin can occur with sympathetic activation, but heart rate is a more direct, objective, and high-yield autonomic sign to assess first.

Question 16

Which nursing goal is most appropriate for a client with a pain disorder?

Accepted Answer

Answer reason: Pain disorder (somatic symptom related) is managed by improving functional coping and reducing maladaptive responses to stress rather than promising complete symptom elimination. A therapeutic nursing goal is to help the client identify stressors, use relaxation/cognitive-behavioral techniques, and engage in healthier behaviors that lessen the impact of symptoms on daily life. Goals like “express relief from pain” set an unrealistic outcome and can reinforce symptom preoccupation and repeated help-seeking. Targeting adaptive coping supports long-term functioning and aligns with evidence-based psychosocial care for somatization presentations.

Question 17

What is the priority nursing diagnosis for a client with hypochondriasis disorder?

Accepted Answer

Answer reason: A priority nursing diagnosis focuses on the client’s ineffective coping and emotional distress that perpetuate reassurance-seeking and functional impairment. This option best captures the pervasive negative outlook and helplessness clients may feel when they believe they are seriously ill despite medical evaluation. The other choices are either unrelated to the typical symptom pattern (visual perceptual disturbance), represent a specific physiologic problem not inherent to the disorder (nutrition deficit), or introduce a safety risk not characteristically primary in this condition (other-directed violence).

Question 18

A surgical client newly diagnosed with cancer tells a nurse she knows the laboratory made a mistake about her diagnosis. Which reaction is this client most likely experiencing?

Accepted Answer

Answer reason: Insisting the lab “made a mistake” reflects an attempt to negate the diagnosis rather than process its implications. Intellectualization would focus on excessive facts/technical details to avoid emotion, not disputing the diagnosis itself. Repression and regression involve unconscious forgetting or reverting to earlier behaviors, which are not reflected in this statement.

Question 19

A client’s condition is becoming stabilized after an episode of substance-induced delirium. During the initial recovery period, the nurse should assess the client for which psychosocial health problem?

Accepted Answer

Answer reason: Screening for depressive symptoms is critical because depression increases relapse risk and can signal suicidal ideation requiring immediate safety interventions. Early identification allows timely referral, supportive counseling, and appropriate pharmacologic/therapy planning as cognition clears. Flashbacks and nightmares are more characteristic of PTSD or specific hallucinogen-related persistent phenomena rather than the most broadly expected early-recovery problem across substances. Dissociation is less typical as a primary post-delirium concern compared with mood symptoms.

Question 20

A nurse is teaching a client with an eating disorder about cues that trigger unhealthy eating behaviors. Which example represents a social cue?

Accepted Answer

Answer reason: Exposure to dieting messages and idealized body standards in advertising can directly trigger restrictive eating, compensatory behaviors, or binge–purge cycles in vulnerable clients. In contrast, troublesome memories and frustration/fatigue are internal emotional states, and interpersonal conflict is an interpersonal stressor rather than a broader social/environmental cue. Teaching clients to identify and limit exposure to these external triggers is a practical relapse-prevention strategy.

Question 21

A client with an ileostomy tells the nurse he is unable to have an erection. The nurse is aware that?

Accepted Answer

Answer reason: Sexual dysfunction after ostomy-related surgery is most strongly linked to pelvic dissection and nerve injury (e.g., low anterior resection, abdominoperineal resection), not to the presence of an ileostomy itself. An ileostomy is typically created without extensive pelvic nerve disruption, so persistent erectile dysfunction is not an expected/common direct outcome. The nurse should recognize this pattern to prompt assessment for other causes (medications, vascular disease, diabetes, psychological stress, or specific surgical nerve damage) and facilitate referral rather than normalizing it as inevitable. Saying function will never return is inaccurate and can increase distress; an abdominal X-ray is not a first-line evaluation for erectile dysfunction. This knowledge supports therapeutic communication and appropriate follow-up planning.

Question 22

A 42-year-old female client complains of painful intercourse. Which nursing diagnosis is most appropriate in planning the client’s care?

Accepted Answer

Answer reason: The most fitting nursing diagnosis targets the problem directly so interventions can focus on pain assessment, screening for vaginal atrophy/infection, medication effects, and anxiety or trauma history, plus education and referral as needed. “Ineffective sexuality patterns” is broader and often relates to altered sexual expression/identity rather than a specific functional problem characterized by pain. “Ineffective coping” and “Disturbed body image” may be associated but are not the primary diagnosis supported by the presented complaint.

Question 23

A nurse is caring for a client who’s demonstrating an ego defense mechanism. Which finding supports the nurse’s observations?

Accepted Answer

Answer reason: Somatization is a classic defense in which psychological conflict is expressed as physical symptoms and excessive focus on bodily complaints. Persistent preoccupation with pain supports this pattern because the client’s emotional distress is channeled into a somatic focus rather than discussed as feelings. In contrast, repression, suppression, and denial are defenses but describe managing thoughts/feelings directly rather than converting distress into physical symptom fixation. This finding best matches a defense-based presentation consistent with somatic symptom patterns.

Question 24

Which nursing diagnosis is appropriate for a client with conversion disorder who has little energy to expend on activities or interactions with friends?

Accepted Answer

Answer reason: The key cue is decreased engagement with friends and activities, which most directly reflects difficulty initiating or maintaining social exchanges. The other options describe different primary problems: powerlessness and hopelessness are mood/cognitive states requiring evidence of perceived lack of control or pervasive despair, and compromised family coping centers on family system responses rather than the client’s peer interaction pattern. Selecting the diagnosis that matches the most prominent defining characteristic supports targeted goals like graded social participation and coping skill development.

Question 25

An intake nurse at a mental health facility is admitting a client with psychosis. Which assessment technique is most valuable to use when planning this client’s care?

Accepted Answer

Answer reason: The MSE directly informs immediate nursing priorities such as safety precautions, need for close observation, reality-based interventions, and urgency of provider notification. A general interview can be limited by disorganized thinking, guardedness, or poor reality testing, making it less reliable without the MSE framework. Reviewing old records is helpful background but cannot substitute for evaluating the client’s present mental state and current risk level. Projective testing like the Rorschach is not an intake priority and has limited utility for rapid, bedside care planning.

Question 26

A client with dissociative identity disorder frequently switches from one personality to another. The nurse can identify the switch by which finding?

Accepted Answer

Answer reason: Rapid blinking, eye-rolling, or other momentary changes in facial expression can be observed as the client shifts between identity states. The other options describe physiologic instability or medication-related extrapyramidal effects rather than a characteristic sign of dissociation. While autonomic changes (eg, tachycardia) can occur with anxiety, they are nonspecific and do not reliably indicate an identity switch. Recognizing observable transition behaviors helps the nurse maintain safety and use grounding/therapeutic communication during the change.

Question 27

The nurse is planning the care for clients recovering from second- or third-degree burns. Which psychosocial nursing problem should be priority?

Accepted Answer

Answer reason: This diagnosis directly targets the patient’s emotional response to altered appearance and anticipated reactions from others, which can drive anxiety, withdrawal, and nonadherence to rehabilitation. In contrast, altered skin integrity is a physiologic/tissue problem rather than a psychosocial priority. Disturbed personal identity is broader and less immediately tied to the predictable, high-impact psychosocial sequelae of burn injury than appearance-related distress.

Question 28

Adult victims of childhood sexual abuse need to be monitored for signs and symptoms of which disorder?

Accepted Answer

Answer reason: In adulthood, this commonly presents as depressive disorders and increased risk of maladaptive self-medication, leading to alcohol and other substance use disorders. Screening and monitoring should therefore focus on affective symptoms (sadness, anhedonia, suicidality) and substance-related impairment because these are high-prevalence, high-morbidity outcomes. PTSD can also occur, but pairing it with OCD is less consistently linked and is not as broadly supported as the depression–substance use association in post-abuse trajectories.

Question 29

When treating a client admitted to the psychiatric unit for transvestic fetishism, the nurse should develop a care plan based on which nursing diagnosis?

Accepted Answer

Answer reason: Nursing care prioritizes assessment of sexual health, triggers, associated anxiety/shame, risk to self/others, and development of healthier coping strategies and therapeutic communication. The other options do not directly address the core problem: health maintenance and bathing deficits are not inherent to this condition, and complicated grieving is not the primary expected response unless specifically supported by additional history. Planning around sexual functioning and psychosocial impact most directly aligns with the presenting psychiatric concern.

Question 30

Which statement is correct regarding conversion disorders?

Accepted Answer

Answer reason: Conversion disorder involves neurologic-like deficits that are not intentionally produced and occur outside the client’s conscious control. The underlying psychological stressor/conflict is typically unconscious (repressed), and the physical symptom serves as an expression of that conflict. Clients are generally not aware of the psychological basis, which is why they may show limited concern (la belle indifférence may be present). A common distractor is the idea that symptoms are controlled or fabricated; that description aligns more with factitious disorder or malingering, not conversion disorder.

Question 31

A client experiencing alcohol withdrawal syndrome says he’s itching everywhere from the bugs on his bed. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Client reports of “bugs” with alcohol withdrawal can reflect tactile hallucinations (formication), but nursing care should first ensure there is no actual medical cause of pruritus or skin injury (e.g., excoriations, bites, scabies, allergic reaction) and assess for complications like scratching-related breakdown. A focused skin assessment addresses safety and physiologic needs while also allowing the nurse to respond therapeutically without validating the hallucination. Asking for details about the “bugs” risks reinforcing the delusion, and bluntly denying the experience can increase agitation; labeling the hallucination directly is less therapeutic than assessing and then reorienting/supporting.

Question 32

A client experiencing alcohol withdrawal syndrome says he sees cockroaches on the ceiling. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Alcohol withdrawal can cause visual hallucinations and illusions that worsen in low-light settings. Providing reality-based environmental modifications (improving lighting, reducing shadows) is a safe, nonconfrontational intervention that can decrease misperceptions without escalating agitation. Directly contradicting the perception can increase anxiety, mistrust, or defensiveness during withdrawal. Questions focused on “where” or “still there” may reinforce the hallucination rather than reduce it and do not address an immediate, modifiable trigger.

Question 33

Which is a sign that a client with a new diagnosis of breast cancer is having difficulty coping?

Accepted Answer

Answer reason: Avoidance and refusal to engage in discussion about the illness or plan of care are common maladaptive coping responses early after a cancer diagnosis. Changing the subject when treatment is mentioned suggests denial/avoidance that can interfere with learning, informed decision-making, and participation in care. Crying can be a normal, adaptive expression of grief and does not by itself indicate ineffective coping. Asking questions and expressing practical concerns (like work disruption) generally reflect engagement, planning, and problem-focused coping.

Question 34

Which statement from a bulimic client shows that she understands the concept of relapse?

Accepted Answer

Answer reason: Relapse prevention teaching emphasizes that setbacks can occur and are managed with a nonjudgmental, problem-solving approach rather than viewed as failure. This statement shows realistic expectations, resilience, and willingness to re-engage in recovery behaviors after a lapse, which is the core of understanding relapse. In contrast, the other statements reflect all-or-nothing thinking and self-blame, which increase shame and can perpetuate the binge–purge cycle. Expressing hope and readiness to restart supports adaptive coping and continued treatment engagement.

Question 35

A young female client with bulimia nervosa tells the nurse she wants to lessen her feelings of powerlessness. What is the most important short-term goal?

Accepted Answer

Answer reason: Powerlessness is addressed most directly by improving the client’s sense of control through effective coping and decision-making. Building problem-solving skills is a concrete, achievable short-term target that helps the client identify options, make choices, and evaluate outcomes, which increases personal agency. Decreasing anxiety may be helpful but does not specifically restore control and can be transient if coping remains ineffective. Limit-setting and daily self-care are useful goals but are either more situational or broader functional targets rather than the primary intervention for the core perception of powerlessness.

Question 36

A 16-year-old client with a diagnosis of undifferentiated schizophrenia has become very clingy and begins sucking her thumb while interacting with the nurse. The nurse interprets this behavior as which of the following?

Accepted Answer

Answer reason: Thumb-sucking and clinginess are age-inappropriate, childlike behaviors that indicate a return to a more infantile coping style. This pattern is consistent with regressive behavior commonly seen in severe anxiety and some psychiatric disorders. By contrast, repression involves unconsciously blocking distressing thoughts, and projection involves attributing one’s unacceptable feelings to others, neither of which matches the observed behavior.

Question 37

The nurse is caring for a client with a paraphiliac disorder. What is the most important goal for the client?

Accepted Answer

Answer reason: A realistic, measurable goal is that the client can identify and articulate acceptable, consensual ways to manage sexual urges and triggers after discharge. This reflects readiness for behavior change and supports relapse prevention planning, which is more clinically meaningful than simple participation in unit activities. Encouraging use of triggers is directly countertherapeutic because it increases risk of compulsive behavior and potential victimization.

Question 38

A nurse lecturing on paraphilias informs her audience that recidivism is high for clients with paraphilias. Which definition best describes recidivism?

Accepted Answer

Answer reason: In paraphilic disorders, it commonly describes resumption of inappropriate sexual behaviors despite treatment efforts, reflecting the chronic, relapsing nature and need for ongoing management and monitoring. “Insight into treatment” describes readiness or engagement, not relapse. “Aggressive sexual assault” is a possible harmful act but is not the definition of recidivism, and “behaviors associated with sexual deviation” defines the content of the disorder rather than recurrence after treatment.

Question 39

Which statement made by a client with paraphilia indicates a potential for relapse?

Accepted Answer

Answer reason: Relapse risk increases when a client shows poor insight, denial, and externalizes responsibility, because these factors reduce motivation to engage in treatment and to use relapse-prevention strategies. This statement reflects minimization of the problem and lack of perceived need for therapy, suggesting low readiness for change and poor adherence. In contrast, expressing intent to attend therapy or considering antiandrogen treatment reflects engagement and willingness to reduce risk factors. Denial/resentment about mandated treatment is a common warning sign that the client may discontinue care and return to maladaptive behaviors.

Question 40

What is a priority nursing goal for a client diagnosed with hypochondriasis?

Accepted Answer

Answer reason: Nursing goals focus on decreasing health anxiety, supporting coping skills, and reducing maladaptive reassurance-seeking while maintaining appropriate medical follow-up. Targeting fear directly aligns with the core problem and helps reduce repeated somatic preoccupation and unnecessary utilization. Sleep assessment may be relevant but is secondary and not the central therapeutic priority. Goals like restoring lost function or reinforcing physical appearance do not address the primary anxiety-based mechanism of the disorder.

Question 41

A client with somatoform disorder states that her frequent headaches result from a brain tumor. However, a tumor hasn’t shown up on diagnostic tests. The nurse interprets the client’s form of somatization as which disorder?

Accepted Answer

Answer reason: Here, the client attributes headaches to a brain tumor even though diagnostic testing has not supported that diagnosis, reflecting misinterpretation of symptoms as evidence of severe disease. Conversion disorder would present with neurologic deficits incompatible with known conditions, not a fixed belief about a tumor. Pain disorder focuses on pain as the predominant symptom with disproportionate impairment, whereas the key feature in this stem is the erroneous disease belief despite negative workup.

Question 42

Which initial therapeutic intervention is the most appropriate for a client diagnosed with ineffective coping related to a pain disorder?

Accepted Answer

Answer reason: Initial psychiatric nursing care follows the nursing process, and assessment must come before planning interventions for coping. With pain disorder/somatic symptom presentations, the nurse needs to establish baseline data on pain characteristics, stressors, functional impairment, current coping patterns, and safety risks (e.g., depression, substance misuse). This comprehensive assessment guides individualized goals and prevents premature or mismatched teaching that can feel invalidating to the client. Interventions like facilitating feelings, building insight, or teaching alternative coping strategies are appropriate later but depend on assessment findings and readiness to engage.

Question 43

A client with a history of depression demonstrates some inconsistent symptoms of cognitive impairment. The nurse should expect which situation when the depression is treated?

Accepted Answer

Answer reason: Depression can produce “pseudodementia,” where attention, concentration, and recall appear impaired but fluctuate and are often inconsistent across situations. When the mood disorder is effectively treated, these cognitive symptoms commonly improve or resolve because the underlying issue is impaired motivation/processing rather than progressive neurodegeneration. Delusions are not a defining feature of typical depression-related cognitive impairment unless psychotic features are present, so their cessation is not the expected general outcome. Suicidal ideation may improve with treatment but cannot be assumed to be eliminated, so it is not the safest expectation.

Question 44

A client with a substance abuse disorder says the problem doesn’t really exist. Which intervention should be the nurse’s initial one?

Accepted Answer

Answer reason: The nurse’s initial intervention is to explore and gently confront the client’s coping/defensive patterns to build insight and readiness for change. This supports therapeutic communication and assessment before moving into teaching or longer-term planning. Broad education may be ineffective until denial is addressed, and focusing on resentment or caregiver needs is premature without first establishing acknowledgement of the problem.

Question 45

The client recently diagnosed with age-related macular degeneration (AMD) in both eyes returns to the clinic for a follow-up appointment. Which assessment will the nurse be certain to include during the visit?

Accepted Answer

Answer reason: AMD can severely impair central vision and reading/driving ability, so psychosocial assessment is a key part of follow-up nursing care to detect mood symptoms early and connect the client to supports and treatment. This assessment is directly tied to the diagnosis and its common, high-impact complication affecting quality of life. The other options are not routine, diagnosis-driven follow-up assessments for AMD in the absence of specific medication risks or comorbid disease cues.

Question 46

The nurse is assessing the client recently admitted into a psychiatric unit for observation. Which client behavior is indicative of impaired cognition?

Accepted Answer

Answer reason: Impaired cognition commonly presents as deficits in orientation, attention, and memory, especially short-term recall. Repeatedly asking the same question suggests the client cannot retain new information or integrate recent events, indicating impaired recent memory and/or confusion. In contrast, mumbling/rambling is primarily a thought-process or speech abnormality, and discussing voices points more toward perceptual disturbance (hallucinations) than cognition. Prolonged staring may reflect depression, withdrawal, or catatonic features, but it does not specifically demonstrate a cognitive deficit as directly as repetitive disorientation-based questioning.

Question 47

A nurse is assessing a client with bulimia nervosa for possible substance abuse. What is the most important question for the nurse to ask the client?

Accepted Answer

Answer reason:  Substance misuse screening should prioritize substances most plausibly linked to the client’s condition and that pose immediate medical risk. In bulimia nervosa, misuse of stimulants and weight-loss agents is common and can worsen dehydration, electrolyte disturbances, tachyarrhythmias, anxiety, and insomnia. This question is direct, nonjudgmental, and clinically focused on a high-yield, condition-associated substance category. By contrast, asking where to buy drugs is not a screening question and can feel accusatory, while peer-offer or age-of-first-drink questions are less targeted to the bulimia-related pattern of misuse.

Question 48

A client with a somatoform pain disorder may obtain primary and secondary gain. Which statement best describes secondary gain?

Accepted Answer

Answer reason: Secondary gain refers to the external benefits a client receives from symptoms, such as attention, sympathy, and special consideration from others. In somatoform pain disorder, these external reinforcers can inadvertently maintain illness behaviors even when no intentional deception is present. Emotional support and increased attention from family or staff are classic examples of such external rewards. In contrast, internal relief of anxiety or resolution of unconscious conflict is primary gain, while avoidance of tasks is another external benefit but is less comprehensive than the broad social reinforcement described here.

Question 49

Based on a nursing diagnosis of ineffective coping for a client with somatoform pain disorder, which nursing goal is most realistic?

Accepted Answer

Answer reason: In somatoform pain disorder, symptoms are real to the client but are closely linked to psychological stress and maladaptive coping, so goals should be achievable and support improved functioning. A realistic short-term outcome is for the client to report decreased intensity/frequency of physical complaints as coping skills and stress management improve. Safety from injury is a general goal but does not directly address ineffective coping in this context. Recognizing sensory impairment and discussing spiritual issues are not core targets for this diagnosis and are not as directly measurable for symptom-focused care planning.

Question 50

The nurse is caring for the 14-year-old child with Addison's disease. Which is an associated problem that the nurse should address?

Accepted Answer

Answer reason: Addison’s disease can be associated with hyperpigmentation, weight loss, fatigue, and decreased stamina, which may negatively affect appearance and confidence in a 14-year-old. This nursing problem is important because it can drive withdrawal, nonadherence to medications, and reduced participation in normal activities. In contrast, fluid volume excess is not typical; adrenal insufficiency more often predisposes to dehydration and hypotension due to mineralocorticoid deficiency.

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