Question 1

A nurse observes that a client with a below-the-knee amputation on the third postoperative day refuses to look at the stump and changes the subject when the nurse attempts to discuss its care. Which nursing diagnosis should the nurse use to address this situation?

Accepted Answer

Answer reason: On postoperative day 3, the client’s refusal and topic-changing reflect denial/avoidance as a coping response to the visible change and anticipated functional/social impact. This diagnosis best directs nursing care toward facilitating adjustment, therapeutic communication, and gradual engagement with stump care. Hopelessness and powerlessness are broader mood/control problems not specifically supported by the behavior described, and impaired mobility is a physical problem rather than the primary psychosocial barrier here.

Question 2

The client recently diagnosed with depression tells the nurse that she is 2 months pregnant and is reluctant to take an antidepressant. Which type of therapy should the nurse discuss when the client asks about an alternate treatment for depression?

Accepted Answer

Answer reason: This approach targets negative automatic thoughts and maladaptive behaviors that maintain depressive symptoms, and it teaches skills (cognitive restructuring, behavioral activation) that can be applied immediately. It has strong efficacy data for mild-to-moderate depression and can be used alone or combined with medication if symptoms later warrant it. By contrast, the other listed approaches are not as consistently supported as primary, structured treatments for depression in this context.

Question 3

A female client with bulimia nervosa tells a nurse she was doing well until last week, when she had a fight with her father. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Bulimia commonly involves using bingeing/purging as a maladaptive coping response to distress and interpersonal conflict. The most appropriate nursing focus is helping the client build insight into the connection between emotions, triggers (e.g., the argument), and eating behaviors so healthier coping can be substituted. This approach supports therapeutic communication and self-awareness, which are central to behavior change in eating disorders. Family therapy may be helpful but is not the most immediate, client-centered nursing intervention for the stated trigger, and advising avoidance of family members is nontherapeutic and can worsen coping.

Question 4

A nurse is obtaining a health history from a client who states he has been diagnosed with voyeurism. Which of the following actions would the nurse expect to assess in this client?

Accepted Answer

Answer reason: This behavior is typically nonconsensual and involves watching rather than direct physical contact. Rubbing against a nonconsenting person instead aligns with frotteurism, while using rubber sheeting for arousal is consistent with fetishistic behavior. Cross-dressing is associated with transvestic disorder, not voyeurism.

Question 5

A mother is concerned about her son and says he’s 10 years old and has been playing with dolls since he was 2. Which initial strategy should be included in his care plan?

Accepted Answer

Answer reason: The priority initial nursing strategy is to reduce caregiver anxiety and promote supportive, nonjudgmental parenting, since parental distress and attempts to restrict play can harm self-esteem and family functioning. Counseling/education for the mother helps correct misconceptions, assess her specific fears, and reinforce acceptance and healthy boundaries. In contrast, discarding toys or pressuring “age-appropriate” play is punitive and may increase shame; focusing on the child’s feelings may be appropriate later if there are signs of distress or impairment.

Question 6

A 46-year-old female client is diagnosed with a problem in sexual functioning. When planning her care, which nursing intervention takes highest priority?

Accepted Answer

Answer reason: Self-awareness is the first priority because unresolved discomfort or values conflicts can lead to judgmental wording, avoidance, or incomplete assessment, which directly undermines subsequent interventions. Once the nurse has clarified personal beliefs and can communicate neutrally, assessment of sexual functioning and relationship factors can be conducted more accurately and respectfully. Interviewing a partner is not initial priority and may be inappropriate without the client’s consent and a clear clinical need.

Question 7

The nurse is preparing a teaching plan for a family who has a member diagnosed with a somatoform disorder. The most important information for the nurse to provide would be that these disorders?

Accepted Answer

Answer reason: Somatoform (somatic symptom–related) disorders involve distressing physical symptoms that are not fully explained by an identifiable medical disease process on assessment and diagnostic testing. Teaching should emphasize that the symptoms are real and cause impairment, but the expected objective/organic pathology is absent or insufficient to account for the presentation. This understanding helps families avoid reinforcing repeated medical workups and instead support consistent follow-up, stress management, and appropriate mental health care. Options describing a single organ system or an organic pathological cause misrepresent the core diagnostic feature and can increase stigma and ineffective care-seeking.

Question 8

The nurse is preparing a care plan for a client experiencing hypochondriasis. What is the most appropriate nursing diagnosis for this client?

Accepted Answer

Answer reason: A risk-focused diagnosis is appropriate because fear can prompt unsafe self-directed actions (e.g., excessive self-exams, misuse of OTC medications, nonadherence to advised activity limits, unnecessary procedures) and can worsen functioning. This option directly links the client’s core symptom—constant fear of illness—to a clinically relevant safety consequence that nursing can address through assessment, reassurance strategies, and coping interventions. The other choices describe problems not central to illness anxiety (unresolved grief, worthlessness-related self-esteem issues, or lack of leisure activity), making them less aligned with the primary presentation.

Question 9

A client has been hospitalized with a diagnosis of conversion-disorder blindness. Which statement best explains this manifestation?

Accepted Answer

Answer reason: Conversion disorder involves unconscious conversion of psychological distress into neurologic-like symptoms without an organic cause. The symptom provides primary gain by reducing internal anxiety/conflict through the physical manifestation, so the client is not intentionally producing symptoms. This explanation directly matches the core mechanism underlying conversion symptoms such as blindness. A common distractor is repression/suppression, which describes a defense but does not specifically account for the functional neurologic symptom as an anxiety-relieving conversion.

Question 10

A client diagnosed with conversion disorder is experiencing left-sided paralysis. The client tells the nurse he has received a lot of attention in the hospital and it’s unfortunate others outside the hospital don’t find him interesting. Which nursing diagnosis is appropriate for this client?

Accepted Answer

Answer reason: The client’s statement highlights reliance on the sick role to obtain interpersonal support, indicating inadequate coping strategies rather than a primary physiologic deficit. The nursing focus is to help the client develop healthier ways to manage stress and meet emotional needs while minimizing reinforcement of symptoms. While decreased outside attention is mentioned, it does not establish withdrawal or aloneness consistent with social isolation, making that distractor less fitting.

Question 11

A nurse is teaching family members about signs and symptoms of conversion disorder to observe for in the client. It is most important for the nurse to include which sign or symptom?

Accepted Answer

Answer reason: g., weakness, paralysis, aphonia, non-epileptic seizures, sensory loss) that are incompatible with known neurologic disease and are linked to psychological stressors or conflict. Teaching families to watch for these functional neurologic symptoms best reflects the defining feature of the disorder and helps prompt appropriate evaluation while avoiding reinforcement of sick-role behavior. Delusions point toward psychotic disorders, not somatic symptom-related conditions. Dread with somatic signs is more consistent with panic/anxiety, and mood changes like depression/euphoria are not the hallmark presentation.

Question 12

A new client admitted to a psychiatric unit is diagnosed with conversion disorder. The client shows a lack of concern for his sudden paralysis, although his athletic abilities have always been a source of pride to him. The nurse understands that the client is demonstrating?

Accepted Answer

Answer reason: Conversion disorder can present with neurologic symptoms that are inconsistent with medical disease, and patients may show an unexpectedly calm or unconcerned attitude toward serious deficits. This apparent lack of distress about sudden paralysis is a classic feature described as a relative emotional indifference to the symptom. Malingering is intentional feigning for external incentives and would not be inferred simply from calm affect. Secondary gain refers to external benefits (e.g., avoiding responsibilities), which may occur but does not specifically describe the client’s indifferent emotional response.

Question 13

Which statement made by a nurse promotes independence in self-care in a client diagnosed with somatoform pain disorder?

Accepted Answer

Answer reason:  The core principle is to promote function and self-care by reinforcing adaptive behaviors and participation rather than reinforcing the sick role. Scheduling and cueing the client to attend group activities encourages engagement, routine, and independence while still offering appropriate structure. In contrast, offering daily help with care or having staff meet basic needs fosters dependency and secondary gain. Delaying activity until pain is gone is maladaptive because somatic symptom disorders often persist and avoidance increases disability and symptom preoccupation.

Question 14

Which verbalization should be cause for concern to a nurse treating a postpartum client within a few days of delivery?

Accepted Answer

Answer reason: A core postpartum safety principle is to distinguish expected “baby blues” (mild, transient mood lability) from concerning depressive symptoms that impair bonding or suggest major depression. Feeling “empty” shortly after delivery can reflect anhedonia, emotional numbness, or detachment, which are more worrisome than simple tearfulness or worry and warrant focused screening for postpartum depression and suicidal ideation. In contrast, nervousness about taking the baby home is a common adjustment response in new parents. Wanting to observe newborn care teaching and requesting nursery care for rest are typical, nonpathologic coping and recovery behaviors in the immediate postpartum period.

Question 15

Family structure is the ordered set of relationships among family parts and between the family and other social systems. In determining the family structure, the nurse needs to identify the?

Accepted Answer

Answer reason: Family structure is primarily defined by who is included in the family unit and how those members relate to each other and to external systems. Identifying the members establishes the boundaries of the system, which is necessary before roles, relationships, power patterns, and interactions can be assessed. Age and gender are descriptive characteristics of individuals but do not, by themselves, determine the composition of the family system. Living arrangements can inform functioning and support patterns, but they are secondary to first determining who belongs to the family.

Question 16

The nurse teaches an alcoholic client the signs and symptoms of alcohol withdrawal. Which statement by the client indicates that he understands the teaching?

Accepted Answer

Answer reason: Alcohol withdrawal reflects CNS hyperexcitability from abrupt loss of alcohol’s depressant effect, producing autonomic overactivity and tremors. Tremulousness (shaking hands), anxiety, diaphoresis, tachycardia, hypertension, and potential seizures/DTs are expected early manifestations after stopping drinking. A slowed heart rate or a drop in blood pressure contradicts the typical sympathetic surge seen in withdrawal. Marked sleepiness is more consistent with intoxication or sedative effects rather than uncomplicated withdrawal.

Question 17

Clients who have substance use disorders fall into one of five stages. These stages occur along a continuum that provides a useful framework for monitoring progress. A client admits to the nurse that substance use is causing difficulties in the client’s life. Which stage is the client experiencing?

Accepted Answer

Answer reason: Recognizing and verbalizing that substance use is causing problems reflects insight and ambivalence, which characterizes the contemplation stage of change. In this stage, the client acknowledges the negative impact and begins considering change but has not yet committed to specific steps. Precontemplation would involve denial or lack of perceived problem, which is not consistent with the client’s admission. Action and maintenance require active behavior change and sustained relapse-prevention efforts, neither of which is indicated by the stem.

Question 18

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." The nurse determines that further discussion should include which concept?

Accepted Answer

Answer reason: The client’s statement signals a lack of growth in areas like purpose, daily structure, emotional regulation, and supportive connections despite sobriety. Exploring goals, values, routines, relapse-prevention supports, and engagement in healthy roles aligns with a broader psychosocial focus on recovery maintenance. Options like education or career may be components of change, but they are narrower and do not directly address the global life-adjustment issue being expressed.

Question 19

A nurse is teaching a client about lifestyle changes that need to be made after a myocardial infarction (MI). The diagnosis of ineffective coping is supported when the client is observed in which action?

Accepted Answer

Answer reason: This behavior indicates impaired reality orientation and ineffective processing of the stressor, which is consistent with ineffective coping. In contrast, reading about meal planning suggests problem-focused coping and engagement in self-care. Occasional pacing or brief quiet time can be normal anxiety or rest behaviors and are not as clearly indicative of maladaptive coping as denial of the MI.

Question 20

The nurse is teaching caregivers about the signs and symptoms of schizophrenia relapse. Which response by the caregivers about the signs and symptoms to report to a mental health professional indicates that the teaching has been effective?

Accepted Answer

Answer reason: This option describes heightened arousal and insomnia, which are common early warning signs caregivers should promptly report so treatment can be adjusted to prevent full relapse. By contrast, increased socialization generally reflects improved functioning rather than deterioration. Appetite or sexual-interest changes can occur for many reasons (including medication effects) and are less specific as early relapse indicators than new anxiety and disrupted sleep.

Question 21

The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10 lb baby. One week following the delivery, the nurse is completing a home visit. Which finding should be the nurse’s priority?

Accepted Answer

Answer reason: In postpartum depression, the top nursing priority is safety—assessing risk for harm to the infant or impaired caregiving. Yelling at the baby suggests escalating irritability, poor impulse control, and potential for unsafe responses (e.g., rough handling/shaking) that require immediate assessment, support, and possible urgent escalation. Crying throughout the visit is consistent with depressive symptoms but is less immediately dangerous than signs of loss of control directed toward the infant. Foul-smelling lochia may indicate infection and needs prompt follow-up, but in this scenario the most urgent, time-sensitive risk is potential infant harm.

Question 22

A female client with bulimia nervosa is discussing her abnormal eating behaviors with the nurse. Which statement by the client indicates an understanding of the disorder?

Accepted Answer

Answer reason: " Bulimia nervosa behaviors are often triggered by negative affect and poor coping with emotions, leading to binge episodes followed by compensatory behaviors. Identifying an emotional antecedent (loneliness) and linking it to bingeing shows insight into the pattern that maintains the disorder. In contrast, attributing improvement to vague future life changes reflects externalization and does not demonstrate understanding of the behavioral-emotional cycle. Recognizing the trigger is clinically important because it supports targeted coping skills training and relapse prevention planning.

Question 23

Which statement made by the client about the binge-purge cycle that occurs with bulimia nervosa indicates understanding of the disorder?

Accepted Answer

Answer reason: Bulimia nervosa commonly involves a recurrent cycle where negative affect (e.g., stress, anxiety, shame) precipitates loss-of-control eating followed by compensatory behaviors to reduce distress and fear of weight gain. Recognizing emotional antecedents reflects insight into the disorder’s maintaining factors and is consistent with targets of CBT (identifying triggers and alternative coping skills). The idea that people “grow out of” bingeing minimizes chronicity and relapse risk. Framing purging as the only problem ignores that binge episodes and the trigger-distress cycle are central to the diagnosis and treatment plan.

Question 24

A nurse plans to include the parents of a client with anorexia nervosa in therapy sessions along with the client. What fact should the nurse remember about parents of clients with anorexia?

Accepted Answer

Answer reason: Family-system patterns commonly associated with anorexia nervosa include overinvolvement, high control, and overprotectiveness, which can reinforce dependence and difficulty with autonomy. In family sessions, recognizing this dynamic helps the nurse guide parents toward supporting healthy independence while avoiding power struggles around food and weight. The other options describe patterns more consistent with different psychiatric contexts (e.g., substance use disorders or some personality/attachment disturbances) rather than typical anorexia family dynamics. This knowledge supports therapeutic communication and effective family interventions during treatment.

Question 25

A client with anorexia nervosa tells a nurse, “My parents never hug me or say I’ve done anything right.” What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Family dynamics that limit emotional expression and validation can reinforce low self-esteem and maladaptive coping patterns seen in eating disorders. The priority intervention is assessment/exploration of how the family communicates affection and approval to identify specific barriers, patterns, and skills deficits. This therapeutic, nonjudgmental approach builds a foundation for targeted family teaching and communication interventions. Options focused on assertiveness training or general social difficulties are premature and less directly tied to the client’s expressed concern about affection and praise.

Question 26

A client with anorexia nervosa tells a nurse, “I’ll never have the slender body I want.” What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Body-image distortion and irrational beliefs about weight/shape are core cognitive features of anorexia nervosa, so nursing care should target these maladaptive perceptions with therapeutic, reality-based support. The client’s statement reflects an unrealistic, perfectionistic standard and negative self-evaluation, which can be explored and reframed to promote healthier self-concept and coping. Interventions focused only on nutrition referrals or exercise planning do not directly address the distorted cognition driving restrictive behaviors and may inadvertently reinforce weight/shape preoccupation. Family involvement can be helpful in some cases, but the most immediate, client-centered response to this statement is to work on realistic body image and related thoughts.

Question 27

The nurse is teaching the family of a client with scatophilia. Which response by the nurse is most accurate in teaching about the characteristics of this disorder?

Accepted Answer

Answer reason: Scatophilia is a paraphilia characterized by sexual arousal associated with obscene or sexually explicit language, commonly via telephone calls. This behavior aligns with the concept of making sexually arousing “obscene phone calls,” which is distinct from object-focused arousal or nonconsensual physical contact. Using nonliving objects corresponds to fetishism, contact with children describes pedophilic disorder, and rubbing against a nonconsenting person is characteristic of frotteuristic disorder. Teaching should emphasize the specific stimulus (obscene verbal content) that defines scatophilia to avoid conflating it with other paraphilias.

Question 28

A 50-year-old client has been taking antihypertensive medication that the physician prescribed. During a routine office visit for blood pressure monitoring, the client tells the nurse that he is unable to have sexual intercourse with his wife anymore. The nurse determines that this is most likely the result of his?

Accepted Answer

Answer reason: Erectile dysfunction is a common adverse effect of several antihypertensive drug classes and is a frequent cause of decreased sexual performance and nonadherence. The key cue is the temporal association with starting ongoing antihypertensive therapy rather than a sudden change in age or baseline stress. Uncontrolled hypertension can contribute to erectile dysfunction via vascular disease, but in a routine follow-up focused on medication use, the medication side effect is the most likely and most testable cause. The appropriate nursing implication is to assess onset relative to medication changes and collaborate with the prescriber about alternatives rather than attributing it to normal aging.

Question 29

Estrogen therapy has been prescribed for a male client who wishes to undergo sexual reassignment surgery. The nurse determines that the client understands the therapy when he states its purpose is to accomplish which of the following?

Accepted Answer

Answer reason: A key expected effect is breast development along with body fat redistribution and decreased spontaneous erections. Estrogen does not create a uterus or ovaries, so it cannot cause menstruation. Cross-dressing is a behavioral/social expression and is not a physiologic effect of estrogen therapy, and increased body hair is associated with androgens rather than estrogen.

Question 30

After a myocardial infarction (MI), a client tells the nurse he’s afraid he’ll have another heart attack if he attempts sexual intercourse. Which nursing diagnosis is most appropriate?

Accepted Answer

Answer reason: The client is expressing fear of triggering another MI, suggesting a need for information about cardiac rehabilitation guidance (e.g., when it is safe, warning symptoms, medication considerations, activity tolerance). A body image diagnosis does not fit because the concern is not about appearance or physical self-perception changes. A sexual dysfunction diagnosis related to self-esteem is less supported because there is no evidence of performance problems or self-worth concerns—only fear and perceived danger.

Question 31

A nurse and senior nursing student are caring for a client with somatoform disorders. The student tells the nurse that associated physical symptoms occur because the client is delusional. What is the best response by the nurse?

Accepted Answer

Answer reason: Somatoform disorders involve physical symptoms that are not intentionally produced and are linked to psychological distress, not fixed false beliefs. The safest teaching response is to redirect the student toward accurate assessment and understanding of the disorder being managed, rather than reinforcing an incorrect label. This option uses a nonjudgmental, educational approach that promotes clarification and appropriate care planning. Focusing on delusions would mischaracterize the client’s presentation and can lead to inappropriate interventions aimed at psychosis.

Question 32

A college student frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. The nurse interprets this as?

Accepted Answer

Answer reason: Persistent preoccupation with having a serious disease despite appropriate medical evaluation and reassurance is the defining feature of illness anxiety (formerly termed hypochondriasis). The pattern of repeated healthcare visits with vague, nonspecific somatic complaints and continued conviction of serious illness after physical causes are ruled out best matches this condition. Conversion disorder would present with neurologic symptoms (e.g., paralysis, blindness) inconsistent with medical disease rather than GI complaints with illness conviction. Depersonalization involves feelings of detachment from self, and an anxiety disorder may trigger somatic symptoms around exams but does not by itself explain the sustained fixed belief of serious illness after negative workup.

Question 33

A client is admitted for abrupt onset of paralysis in his left arm. Although no physiological cause has been found, the symptoms are exacerbated when he speaks of losing custody of his children in a recent divorce. These assessment findings are characteristic of which of the following disorders?

Accepted Answer

Answer reason: g., weakness or paralysis) and are not explained by a neurologic disease after appropriate evaluation. Symptoms typically occur in association with psychological stressors and may worsen when stress is discussed, reflecting unconscious symptom production rather than intentional fabrication. The timing with divorce-related distress and lack of physiologic findings aligns with this pattern. Malingering is less likely because it involves deliberate symptom production for external gain, which is not supported by the scenario’s emphasis on stress-linked exacerbation rather than a goal-directed presentation.

Question 34

A client diagnosed with conversion disorder has a nursing diagnosis of interrupted family processes related to the client’s disability. Which goal is appropriate for this client?

Accepted Answer

Answer reason: In conversion disorder, symptoms are not intentionally produced and can disrupt function, so nursing goals emphasize maintaining and gradually restoring independence and role functioning. An appropriate outcome is re-engagement in usual responsibilities to reduce disability reinforcement and support healthier coping and family stability. Goals that promote dependence or role reversal can inadvertently reinforce symptoms and further interrupt family processes. Focusing primarily on family problems shifts attention away from adaptive functioning and does not directly address restoring the client’s role performance.

Question 35

A client with a diagnosis of somatoform disorder has been admitted to the psychiatric unit and has difficulty breathing, numbness, and loss of movement in his left arm. He seems unusually calm and unconcerned about his loss. The nurse recognizes these symptoms as which disorder?

Accepted Answer

Answer reason: g., weakness/paralysis, numbness, dyspnea sensation) that are inconsistent with known medical disease and are linked to psychological factors. The client’s motor and sensory deficits in the left arm alongside breathing difficulty fit this functional neurologic presentation. The noted calm, indifferent attitude toward significant symptoms is consistent with la belle indifférence, a classic associated finding. Hypochondriasis centers on fear of having a serious illness, body dysmorphic disorder focuses on perceived appearance flaws, and pain disorder is dominated by pain rather than neurologic deficits.

Question 36

One theory commonly used in family mental health nursing is Bowen’s family systems theory. The central assumption in this theory is that chronic anxiety is the underlying basis for dysfunction. The theory consists of eight interlocking concepts that address anxiety and emotional processes. This includes?

Accepted Answer

Answer reason: Bowen family systems theory emphasizes how individuals manage emotional reactivity and maintain autonomy while staying connected to the family unit. One of its core constructs is the ability to separate thinking from feeling and to function based on values rather than being driven by the family’s anxiety. That capacity is captured by the concept of differentiation, which directly links to chronic anxiety and emotional process patterns in families. The other options are either unrelated to family systems theory or use nonstandard/incorrect terminology that is not one of Bowen’s recognized concepts.

Question 37

During a manic state, a client paced around the dayroom for 3 days. He talked to the furniture, proclaimed he was a king, and refused to partake in unit activities. Which nursing diagnosis has priority?

Accepted Answer

Answer reason: A client pacing for days and refusing unit activities is at high risk for inadequate caloric intake, dehydration, and exhaustion, which can rapidly lead to clinical deterioration. Compared with communication and coping problems, meeting basic physiologic needs takes priority under ABCs/Maslow and acute safety/medical stability principles. Self-directed violence risk is not supported by the stem (no suicidal cues), whereas the prolonged pacing strongly supports a nutrition/energy deficit problem needing prompt intervention.

Question 38

A client has traits of an avoidant personality disorder. Which family intervention should the nurse give the highest priority in the care plan?

Accepted Answer

Answer reason: Coaching the family to recognize and avoid critical, shaming, or overly evaluative communication reduces anxiety and defensiveness and supports engagement in treatment. This foundational change in the home environment improves the client’s willingness to try new interactions and accept support. Teaching social skills can be helpful later, but it is less effective if the client remains guarded due to fear of criticism. Keeping a daily log may increase self-consciousness and perceived scrutiny, worsening avoidance.

Question 39

The client, who is Hispanic, had a radical neck dissection to treat a large facial tumor. Which initial action by the nurse would best determine if the client has an altered body image from the procedure?

Accepted Answer

Answer reason: Altered body image is best identified first through a focused psychosocial assessment of the client’s own perceptions and behaviors. Monitoring verbal statements (e.g., shame, avoidance, self-deprecating comments) and nonverbal cues (avoiding touch, turning away, reluctance to interact) provides direct, culturally sensitive data without forcing confrontation. Asking the client to look in a mirror can be distressing and is not the least intrusive initial step. Focusing on family reactions or offering a minimizing statement does not assess the client’s body image and may inhibit disclosure.

Question 40

The client diagnosed with paraphilia has been advised to participate in psychoanalytical therapy and asks the nurse about the therapy. Which statement by the nurse is correct?

Accepted Answer

Answer reason: Psychoanalytic therapy is based on the principle that unconscious processes and early life experiences shape current maladaptive behaviors and impulses. It aims to increase insight by exploring childhood conflicts, defenses, and underlying motivations that drive symptoms. This matches the goal of addressing the roots of problematic sexual behaviors rather than applying a direct behavioral suppression method. By contrast, aversion techniques and satiation are behavioral therapies, and reducing circulating androgens is a biological/medical intervention rather than psychoanalytic treatment.

Question 41

The client on a psychiatric unit is very demanding and belittling of one of the nurses. The client is talking with others and telling them how mean the nurse is to clients. Which nursing problem should the nurse include in the client’s written plan of care?

Accepted Answer

Answer reason: Splitting is commonly seen with personality disorders and is often driven by poor self-concept and difficulty tolerating ambivalence, making an underlying self-esteem problem a fitting nursing diagnosis focus. The plan of care should target consistent limit-setting, staff communication, and helping the client use more adaptive coping and interpersonal strategies. Options about social isolation or violence risk do not best match the primary pattern because the client is actively engaging others and the comments alone do not indicate imminent intent to harm.

Question 42

The client with a dissociative identity disorder (DID) has amnesia. Which intervention should the nurse initially implement?

Accepted Answer

Answer reason: Initial DID care prioritizes safety and stabilization by reducing confusion and supporting orientation and continuity when memory gaps are present. Sharing factual, nonjudgmental information the team has gathered can help the client understand discrepancies in time and events and lowers anxiety related to amnesia. In contrast, using sensory cues to retrieve memories can be destabilizing and may trigger traumatic recollections before adequate coping skills and support are established. Also, limiting the therapeutic relationship to only one personality is not realistic in DID and can undermine rapport and consistency of care across identity states.

Question 43

The client of Latino/Hispanic ethnicity reports poor appetite, lack of energy, and feeling hopeless nearly every day for the past 3 weeks. The admitting nurse notices that the client does not make eye contact upon questioning. What is the most likely explanation for the client’s behavior?

Accepted Answer

Answer reason: In many Latino/Hispanic cultural contexts, avoiding direct or prolonged eye contact with authority figures can be a sign of respect rather than pathology. The depressive symptoms described support a mood concern, but they do not specifically explain decreased eye contact as a primary indicator of suicidality or psychosis. Suicidality requires direct assessment of self-harm thoughts, plan, and intent rather than inference from eye contact behavior. Psychosis would more typically be suggested by hallucinations, delusions, or disorganized behavior, none of which are described.

Question 44

A parent with a daughter who was diagnosed with bulimia nervosa asks a nurse, “How can my child have an eating disorder when she isn’t underweight?” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Bulimia nervosa is characterized by recurrent binge eating with compensatory behaviors (e.g., vomiting, laxatives, excessive exercise), and many clients remain at a normal or near-normal weight, so absence of underweight does not rule it out. This response directly answers the parent’s misconception with accurate, concrete education, which is the priority in this teaching moment. Option B offers empathy but does not correct the misunderstanding. Option C is inaccurate because weight loss is not an expected “later” finding in bulimia, and option D is supportive but less directly addresses the parent’s specific question.

Question 45

The nurse has instructed a client with an eating disorder about Prozac (fluoxetine). The nurse determines that teaching has been effective when the client makes which statement?

Accepted Answer

Answer reason: " SSRIs have a delayed onset, with clinically meaningful improvement typically emerging after 1–3 weeks (and sometimes longer). Knowing this helps prevent premature discontinuation and supports adherence during the early phase when symptoms may not yet improve. Claims that the medication will “control” eating and allow unrestricted intake reflect misunderstanding of treatment and the need for structured therapy/nutrition plans. Driving is not the key teaching point for fluoxetine, and “calling for cravings” is not a standard urgent adverse-effect teaching target compared with monitoring mood changes, serotonin syndrome symptoms, and adherence expectations.

Question 46

A nurse is preparing the teaching plan for a newly married female client with a cervical spinal cord injury. The client does not want to become pregnant at this time. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: A high cervical spinal cord injury commonly limits hand function and fine motor control, so contraception requiring self-insertion may be impractical and lead to inconsistent use. Teaching the partner to correctly place a barrier method supports reliable, immediate pregnancy prevention while preserving sexual autonomy and intimacy. The rhythm method has a higher failure rate and depends on precise cycle tracking, making it a poor choice when avoiding pregnancy is the priority. Providing general brochures or focusing on a permanent procedure does not address the client’s immediate, reversible contraceptive needs and functional limitations.

Question 47

A 32-year-old client who engages in voyeurism has come to the hospital for treatment so his family and friends don’t find out. The nurse planning care for this client should include which intervention?

Accepted Answer

Answer reason: Voyeurism involves maladaptive sexual behavior that can cause distress/impairment and potential legal/ethical harm, so care should focus on confidential, structured treatment aimed at behavior change and insight. Individual therapy provides a safe setting to explore triggers, distorted beliefs, impulse control strategies, and to develop relapse-prevention plans without unnecessary exposure or shaming. Forcing disclosure to family/friends violates therapeutic boundaries and confidentiality and is not required for treatment. Excluding the client from care planning undermines therapeutic alliance, and simply “evaluating defense mechanisms” is incomplete compared with actively connecting the client to appropriate psychotherapy.

Question 48

A recently divorced 40-year-old client who has undergone radiation therapy for testicular cancer tells the nurse he is unable to achieve an erection. Which nursing diagnosis is most appropriate?

Accepted Answer

Answer reason: Erectile difficulty is a classic defining characteristic of sexual dysfunction, and prior pelvic/testicular cancer treatment can contribute via neurovascular or hormonal effects and psychological stressors. The diagnosis also correctly links the problem to a plausible related factor (radiation therapy effects). Other options could be relevant in broader assessment, but they do not match the primary, specific complaint as directly as a sexuality-pattern diagnosis does.

Question 49

A transsexual client wishes to have a sexual reassignment operation and tells the nurse he’s ready to begin hormonal therapy. Which fact about the client must be true before estrogen therapy is administered?

Accepted Answer

Answer reason: Initiation of gender-affirming hormone therapy requires confirmation of persistent, well-documented gender dysphoria and the individual’s ability to make an informed decision, often supported by a sustained real-life experience living in the affirmed gender role. A history of living in the desired gender role over time is used to demonstrate stability and consistency of the individual’s gender identity and readiness for the irreversible and medically significant effects of hormones. Deciding against surgery or seeking more psychotherapy are not prerequisites to start hormones and do not establish readiness. Sexual functioning “as a female” is neither required nor an appropriate clinical criterion for determining eligibility for estrogen therapy.

Question 50

The nurse is teaching a student nurse about somatoform disorders. Which of the following statements by the nurse would be the most accurate in describing somatoform disorders?

Accepted Answer

Answer reason: Somatic symptom–related disorders are characterized by distressing physical symptoms and excessive thoughts/feelings/behaviors related to those symptoms when they are not fully explained by a medical condition. The defining concept is the presence of physical complaints with a primary psychological component rather than an identifiable organic pathology that accounts for the severity. Psychotherapy may be part of treatment but is not what describes the disorder. Labeling clients as “hypochondriacs” is outdated and inaccurate, and frustration about not finding a cause can occur but is not the core defining feature.

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