Question 1

A nurse is instructing a 38-year-old male client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam (Ativan) 1 mg by mouth three times per day. The nurse determines that the teaching regarding the client’s medication has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Caffeine is a CNS stimulant that can worsen anxiety and interfere with sleep, counteracting the intended anxiolytic and hypnotic effects of a benzodiazepine. Lorazepam is used to reduce anxiety and promote rest, so limiting stimulants supports the treatment plan and improves symptom control. Avoiding aged cheese is a key dietary teaching for MAO inhibitors due to tyramine-related hypertensive crisis risk, not for lorazepam. Photosensitivity precautions and salt-intake guidance do not apply to benzodiazepines as primary patient teaching points.

Question 2

A nurse is teaching the family of a client diagnosed with a somatoform pain disorder. Which of the following statements by the nurse most accurately describes this disorder?

Accepted Answer

Answer reason: This option best captures the hallmark focus on pain and preoccupation with it, without an identifiable physical disease driving the symptoms. The choice describing a general somatic complaint without organic findings is broader and aligns more with somatic symptom disorder overall rather than the pain-focused subtype. The morbid fear of having a serious disease reflects illness anxiety disorder, and neurological symptoms tied to conflict describe conversion disorder.

Question 3

A home health nurse is caring for a client diagnosed with a conversion disorder manifested by paralysis in the left arm. An organic cause for the deficit has been ruled out. Which nursing intervention is most appropriate for this client?

Accepted Answer

Answer reason: Conversion disorder symptoms are neurologic-appearing deficits without an organic basis and are typically linked to psychological conflict expressed somatically. The appropriate nursing approach is to assess for and address the stressors and the reinforcement the symptom may provide (primary gain = relief from anxiety/conflict; secondary gain = external benefits such as attention or avoiding responsibilities). Interventions that increase focus on the symptom or promote avoidance can reinforce the behavior and worsen functional impairment. Supporting independence and gradually increasing activity while exploring underlying stressors is therapeutic, whereas doing tasks for the client or encouraging withdrawal is counterproductive.

Question 4

The nurse is caring for an 86-year-old client in an extended care facility who is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. The nurse determines these symptoms are associated with which disorder?

Accepted Answer

Answer reason: In older adults, this pattern commonly presents as multiple shifting bodily symptoms and frequent reassurance seeking, which can impair appetite and daily functioning. Conversion disorder is more specifically a neurologic-type deficit (e.g., paralysis, blindness) inconsistent with medical disease rather than generalized vague complaints. Severe anxiety can cause somatic sensations, but the hallmark here is the ongoing focus on multiple bodily symptoms as the primary complaint pattern.

Question 5

A nurse is caring for a client who has been diagnosed with alcoholism in an acute care mental health unit. The client has been referred to Alcoholics Anonymous (AA). Which statement best indicates that the client is ready to begin the AA program?

Accepted Answer

Answer reason:  AA is based on acknowledging loss of control over alcohol and accepting the need for help, which reflects movement out of denial and into readiness for change. This statement demonstrates insight, acceptance, and willingness to engage in a recovery program—core prerequisites for benefiting from AA’s first steps. Option B expresses curiosity and a vague expectation of benefit but does not clearly show acceptance of powerlessness or commitment. Option C indicates a role (sponsoring) that is appropriate only after sustained sobriety and program participation, not at initiation. Option D emphasizes external support, which may help adherence, but it does not demonstrate the client’s own acceptance of the problem or readiness to work the program.

Question 6

A 46-year-old single female client is concerned about her 15-year-old son’s behavior. He has suddenly decided his mother shouldn’t date or have men in the house. He told his mother he was the “man of the house.” Which disturbance is occurring in the internal dynamics of the family?

Accepted Answer

Answer reason: Role reversal (parentification) occurs when a child attempts to assume adult authority and decision-making roles that belong to the parent. The teen’s statement that he is the “man of the house” and his attempt to control the mother’s dating life reflect an inappropriate shift in family boundaries and hierarchy. This is not typical age-appropriate adolescent behavior, which may include seeking autonomy rather than policing a parent’s intimate relationships. The central disturbance is the child moving into the parental role, creating dysfunctional internal family dynamics.

Question 7

During the orientation of new staff to the mental health unit, the nurse states, "I’m not sure how I’ll react when faced with a violent client." Which response by the nurse manager would enhance the nurse’s self-awareness?

Accepted Answer

Answer reason: " Self-awareness in psychiatric nursing focuses on recognizing one’s own feelings, triggers, and typical behavioral responses so they can be managed therapeutically and safely. This prompt directs the nurse to reflect on personal patterns when confronted with anger/aggression, which helps anticipate countertransference and maintain calm, consistent limit-setting. The other options shift the focus to techniques or external history-taking rather than the nurse’s internal reactions. Reflection on usual responses is the most direct strategy to build insight and emotional regulation before encountering a violent client.

Question 8

During a home visit to the client with Alzheimer’s disease, the nurse attempts to determine whether the client’s daughter understands her father’s prognosis. Which question by the daughter best indicates an understanding of the prognosis of Alzheimer’s disease?

Accepted Answer

Answer reason:  Alzheimer’s disease is a progressive, irreversible neurocognitive disorder, so prognosis centers on gradual functional decline and increasing need for supervision and caregiver support rather than cure. Seeking community resources (e.g., respite care, adult day programs, home health, caregiver support groups) reflects realistic planning for anticipated progression and safety needs. Questions focused on improving memory or expecting a clear medication “kick-in” timeline suggest an expectation of reversal or substantial restoration, which is not typical. Choosing a “best treatment program” implies a curative or definitive treatment pathway, whereas care is primarily supportive and focused on quality of life and caregiver burden reduction.

Question 9

The client has been seeking treatment for insomnia secondary to situational depression. Which statement made by the client requires follow-up by the nurse?

Accepted Answer

Answer reason:  Sleep hygiene principles emphasize minimizing stimulants and behaviors that increase arousal close to bedtime to reduce insomnia. Black tea contains caffeine, which can delay sleep onset, reduce total sleep time, and worsen sleep fragmentation, making it a maladaptive bedtime routine that warrants further teaching. A light snack may be reasonable depending on content and timing, but pairing it with a caffeinated beverage is a key red flag in insomnia management. The other statements reflect appropriate evaluation of alternative causes, relaxing pre-sleep routines, and realistic linkage between mood improvement and better sleep.

Question 10

The nurse in the ED is assessing the client who was injured in a car accident. The nurse considers that the client may have psychogenic amnesia when the client is unable to recall any personal information. Which statement that reflects the nurse’s critical thinking about psychogenic amnesia is correct?

Accepted Answer

Answer reason: Psychogenic (dissociative) amnesia is typically triggered by severe stress or trauma and presents with inability to recall important autobiographical information without an underlying neurologic cause. In dissociative amnesia with fugue features, the person may travel or wander and can appear confused about identity and surroundings, making disorientation and wandering clinically consistent. The condition is often abrupt in onset and usually transient, which makes a “long-lasting condition” statement less accurate. It is classified as a dissociative disorder rather than a neurocognitive disorder like dementia, so grouping it with dementia reflects an incorrect framework for assessment and care planning.

Question 11

The Native American client is being assessed for emotional distress following a family crisis. In anticipating pharmacological treatment, the nurse understands that the Native American client would most likely do what?

Accepted Answer

Answer reason: Many Native American clients may incorporate herbal/plant-based remedies and traditional healing alongside or before accepting Western pharmacologic approaches, making medication reconciliation and safety screening essential. This option most directly reflects a commonly taught cultural consideration relevant to pharmacologic planning (e.g., potential herb–drug interactions and adherence). The other options are more variable individual or family-pattern generalizations and are less directly tied to anticipating pharmacologic treatment needs and risks.

Question 12

The nurse is in the working phase of a relationship with the client being treated for substance abuse. Which intervention would be appropriate during this phase of treatment?

Accepted Answer

Answer reason: Evaluating how well newly learned coping skills are working is a key working-phase task because it guides reinforcement of effective strategies and revision of ineffective ones. In contrast, assessing readiness to change and determining impairment are more characteristic of early assessment/orientation activities. Although confrontation may occur therapeutically, the hallmark of the working phase is active skills use with ongoing evaluation and refinement.

Question 13

After repeated office visits and diagnostic tests for assorted complaints, a client is referred to a psychiatrist. The client states, “I can’t imagine why I should see a psychiatrist.” What is the most likely explanation for the client’s statement?

Accepted Answer

Answer reason: Somatic symptom–related presentations commonly involve physical complaints that are experienced as real and distressing, while the client has limited insight into psychological contributors. Repeated visits and negative/assorted diagnostic workups suggest persistent somatic focus rather than a missed medical diagnosis or deliberate manipulation. The statement indicates confusion about why psychiatric care is relevant, which aligns with a lack of understanding about how stress and emotional factors can amplify bodily symptoms. Misinterpretations such as physician rejection or diagnostic error can occur, but the most typical underlying issue is poor recognition of the mind–body relationship and need for integrated treatment.

Question 14

A client with hypochondriasis complains of pain in his right side that he hasn’t had before. Which response by the nurse is best?

Accepted Answer

Answer reason: “I’ll report this pain to your physician. In the meantime, group therapy starts in 5 minutes. You must leave now to be on time.” New physical complaints must be taken seriously and medically evaluated to avoid missing an actual acute condition, even in a client with illness-anxiety/hypochondriasis. At the same time, nursing management aims to limit reinforcement of somatic preoccupation by maintaining the treatment routine and focusing on functional goals. This response validates the concern through appropriate referral without rewarding symptom focus with special attention or secondary gains such as avoiding programmed therapy. Options that excuse the client from group or offer new analgesics primarily to relieve anxiety can inadvertently reinforce the maladaptive pattern and increase future symptom-reporting.

Question 15

Which of the following responses would a nurse expect from a client with a narcissistic personality disorder?

Accepted Answer

Answer reason: " Narcissistic personality disorder is characterized by entitlement, grandiosity, and exploitative or demanding behavior toward others. This statement reflects an expectation of special treatment and a transactional, blaming stance toward staff, which aligns with entitlement and lack of empathy. In contrast, idealizing one nurse while devaluing others is more typical of splitting seen in borderline traits. The indecisiveness and reliance on others for choices is more consistent with dependent personality features rather than narcissistic traits.

Question 16

Clients with serious mental illness are not limited to a single symptom or diagnosis. Adult or elderly schizophrenics sometimes present with petulance and temper tantrums. How can the nurse best understand this childish behavior in the context of a complex psychotic person?

Accepted Answer

Answer reason: Regression is a defense mechanism in which a person under stress reverts to earlier, less mature behaviors to cope with overwhelming anxiety. In psychotic disorders, limited coping skills and impaired reality testing can make childlike outbursts a maladaptive but understandable stress response rather than willful misconduct. This interpretation supports therapeutic, nonjudgmental nursing care focused on reducing anxiety and maintaining safety. Attributing the behavior to intentional deception or character flaws can escalate agitation and misses the mental health coping framework central to schizophrenia care.

Question 17

The nurse is caring for a 58-year-old male client diagnosed with paranoid schizophrenia. The client says, “The earth and the roof of the house rule the political structure with particles of rain.” The nurse interprets this statement as which of the following?

Accepted Answer

Answer reason: The sentence strings together unrelated concepts (earth, roof, political structure, rain) without a coherent meaning or goal-directed message. Tangentiality would involve drifting off-topic but still having some connection to the original idea, whereas here the connections are essentially absent. Perseveration is inappropriate repetition of a word/idea, and thought blocking is an abrupt stop in speech, neither of which is demonstrated.

Question 18

During a home visit, the client’s spouse reports that since her husband’s placement of a colostomy 3 months ago, he has lost interest in golf. She also says he cries often for no reason, sleeps for only a few hours at night, and reports fatigue. The wife asks the nurse for advice. Which statement should be the basis for the nurse’s response?

Accepted Answer

Answer reason: These symptoms (anhedonia, frequent crying, insomnia, fatigue) are classic indicators of depression following a major life change and altered body function/body image. The most appropriate nursing basis is recognizing depression as a common, treatable postoperative psychosocial complication so the nurse can assess severity, screen for suicidality, and facilitate referral and support. This framing validates the spouse’s concerns and shifts care toward mental health evaluation rather than normalizing or dismissing the behavior. By contrast, implying the client “should have accepted” the change is judgmental and can worsen shame and delay needed treatment.

Question 19

The nurse is educating the client about prescription antidepressant medications and the appropriate expectations when taking these medications. Which statement by the nurse is accurate?

Accepted Answer

Answer reason:  Antidepressants typically require ongoing adherence to achieve and maintain remission and to reduce relapse risk, so stopping when mood improves can lead to recurrence. Therapeutic effects for most antidepressants generally take weeks, not days, making the 72-hour expectation inaccurate. “Most potent SSRI” is not a standard or clinically meaningful teaching point for fluoxetine, and potency comparisons are not used to guide routine patient counseling. Dry mouth, blurred vision, and urinary retention are more characteristic of anticholinergic effects (e.g., tricyclics) rather than common SSRI effects, which more often include GI upset, insomnia, and sexual dysfunction.

Question 20

The nurse is assessing the older adult postoperative client who is displaying signs of delirium. The nurse observes that the client is convinced that it is 1954 and is complaining about "the bugs in this hotel." Which should be the nurse’s priority intervention?

Accepted Answer

Answer reason: Delirium is an acute confusional state with impaired attention and perception that places postoperative older adults at high risk for falls, pulling lines/tubes, and other safety events. The immediate nursing priority is to increase observation and provide a safe environment so changes can be detected and addressed quickly. Moving the client closer to the nurses’ station enables frequent reorientation, rapid response to agitation, and earlier recognition of deterioration (e.g., hypoxia, infection, medication effects). Sedating medication is not a first-line priority unless the client is a danger to self/others, and relying on family or a sitter may be helpful but is less reliable for immediate continuous nursing surveillance compared with proximity to staff.

Question 21

The client uses methamphetamine regularly. Which subjective quote documented by the nurse demonstrates the client using pathological projection as a coping mechanism?

Accepted Answer

Answer reason: “My dad and I don’t get along. He thinks that I’m a failure and can’t do anything right.” Projection is a defense mechanism in which a person attributes their own unacceptable feelings or self-judgments to someone else. This statement externalizes a likely internal sense of failure by assigning the critical belief to the father as the source. That pattern reflects pathological projection rather than insight or accountability. By contrast, minimizing substance-related harm (e.g., denying an alcohol problem) is more consistent with denial, not projection.

Question 22

A mother of a female client with bulimia nervosa asks a nurse if bulimia nervosa will stop her daughter from menstruating. What is the best response by the nurse?

Accepted Answer

Answer reason:  Menstrual changes in eating disorders are driven by nutritional status, body fat, and neuroendocrine disruption of the hypothalamic–pituitary–ovarian axis, which can vary widely in bulimia nervosa. Some clients maintain near-normal weight and may continue to menstruate, while others develop oligomenorrhea or amenorrhea if malnutrition and physiologic stress are significant. Absolute statements are inaccurate because not all individuals with bulimia develop amenorrhea, and timing is not predictable. This response provides accurate education without blaming and reflects the variable clinical presentation based on severity.

Question 23

A nurse is talking to a client with bulimia nervosa about the complications of laxative abuse. Which statement by the client indicates that the client understands the risks?

Accepted Answer

Answer reason:  Laxative abuse in bulimia is dangerous because it drives fluid and electrolyte losses and disrupts normal bowel function, leading to dehydration, hypokalemia, and potential dysrhythmias. This statement reflects understanding that laxative misuse can compromise nutritional status rather than being benign or an effective weight-control strategy. It also rejects the common misconception that laxatives meaningfully “remove calories,” since most calorie absorption occurs in the small intestine before the colon is affected. By acknowledging physiologic harm, the client demonstrates improved insight into the risks associated with the behavior.

Question 24

A 26-year-old client is diagnosed with somatoform disorder. What is the most important information for the nurse to provide when discussing the care plan with the client’s wife?

Accepted Answer

Answer reason:  Somatic symptom presentations are experienced by the client as real distress, and directly challenging or accusing the client typically increases anxiety, defensiveness, and symptom focus. The care plan emphasizes a supportive, nonjudgmental stance that validates the client’s experience while gradually shifting attention toward coping skills and functional goals. Family guidance should reduce reinforcement of sick-role behavior without arguing about whether symptoms are “real.” Options that label symptoms as “all in his head,” “attention-seeking,” or “on purpose” are stigmatizing, undermine therapeutic rapport, and can worsen symptoms and family conflict.

Question 25

The Neuman’s Systems Model maintains that each person (or group of persons) constitutes a system of five variables: physiological, psychological, sociocultural, developmental, and spiritual. These variables exist along a developmental continuum. The spiritual continuum can range from lack of awareness or denial of spirituality to a highly developed spiritual consciousness. A nurse who allows Neuman’s Systems Model to guide practice should address the client’s level of spiritual awareness or development and address any identifiable spiritual needs occurring in reaction to the?

Accepted Answer

Answer reason: Spirituality in nursing assessment focuses on a person’s sense of meaning, purpose, and connection, especially when facing stressors. This option directly targets the client’s meaning-making, which is the core of spiritual awareness/development in Neuman’s model and guides appropriate spiritual support interventions. By contrast, resources for coping are more aligned with psychological/sociocultural coping capacity rather than spiritual appraisal. “Stress of surgery” is an example of a stressor itself, but spiritual needs are assessed in the client’s interpretation and response to the stressor, not the stressor label.

Question 26

The theoretical support for spiritual caregiving is recognized by professional organizations that influence nursing practice and education. Some professional organizations have issues mandating that nurses offer spiritual care to clients and teach spiritual care to nursing students. Which organization meets these criteria?

Accepted Answer

Answer reason: Nursing ethical standards establish that care is holistic and includes attention to psychosocial and spiritual needs when relevant to the client’s values and wellbeing. The ANA Code of Ethics guides nursing practice and education by defining professional responsibilities, including respecting human dignity and supporting the client’s right to spiritual and cultural beliefs in care. This makes it the clearest professional nursing organization document that can be cited as mandating spiritual considerations in nursing roles. By contrast, agencies like DHS and accrediting bodies focus more on regulation and institutional standards rather than defining the nurse’s ethical duty to provide spiritual support and teach it as part of nursing professional formation.

Question 27

In following which is not included in the 4 A’s of schizophrenia-?

Accepted Answer

Answer reason: These represent characteristic disturbances in emotion, thought process, and interpersonal relatedness rather than a nonspecific emotional state. Anxiety can occur in many psychiatric conditions and may be present in schizophrenia, but it is not one of the traditional four A’s. Therefore it is the option that does not belong to the set.

Question 28

The nurse educates a student about caring for clients in a manic state. Which comment by the student indicates to the nurse that further education is needed?

Accepted Answer

Answer reason: " Mania is characterized by heightened stimulation, distractibility, impulsivity, and poor boundaries, so nursing care prioritizes safety and reducing environmental stimuli. Group activities can be overly stimulating and can escalate agitation, disruptive behavior, and poor impulse control, especially early in the manic phase. More appropriate care includes meeting physiologic needs with portable nutrition and fluids and providing structure with frequent reminders for sleep, hygiene, and toileting. A common pitfall is assuming increased socialization is therapeutic; in acute mania, calm, brief, one-to-one interactions in a low-stimulation setting are typically safer and more effective.

Question 29

The clinic nurse is preparing to discuss the concepts of Kohlberg's theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level?

Accepted Answer

Answer reason: The child evaluates actions as “good” if they avoid punishment or bring a reward, reflecting an egocentric, consequence-driven perspective. This matches the focus on obedience and instrumental exchange characteristic of the earliest stages. In contrast, peer or broader social pressure aligns more with conventional reasoning, where behavior is guided by approval, rules, and maintaining social order.

Question 30

A client with schizophrenia has been stable for some time. What action is most important for preventing relapse?

Accepted Answer

Answer reason: Consistent use reduces risk of psychotic decompensation and rehospitalization more than psychosocial interventions alone. Group therapy, family support, and social skills training can improve functioning and support adherence, but they do not replace the core need for ongoing pharmacotherapy. Therefore the priority action is ensuring the regimen is taken as prescribed and barriers to adherence are addressed.

Question 31

A client with schizophrenia is exhibiting delusions, hallucinations, minimal self-care, and hyperactive behavior. Which of the following would the nurse document as a negative symptom of schizophrenia?

Accepted Answer

Answer reason: g., motivation, affect, social/occupational functioning, and self-care). Impaired self-care is a classic negative manifestation due to avolition/apathy and reduced goal-directed behavior. Delusions and hallucinations are positive symptoms because they represent added experiences or distorted perceptions. Inappropriate affect is more consistent with affective disturbance/disorganization, but the best single negative symptom listed is the functional decline seen in reduced self-care.

Question 32

The nurse has attended a staff education program about catatonia. Which of the following statements by the nurse would require follow-up?

Accepted Answer

Answer reason: " Catatonia is characterized by psychomotor disturbances such as stupor, mutism, negativism, posturing, waxy flexibility, echolalia, echopraxia, or periods of agitated, purposeless activity. The “limp and floppy limbs” description suggests flaccidity, which is not a typical defining feature of catatonia and may point to other neurologic or medication-related causes that require different assessment. In contrast, not speaking (mutism), copying movements (echopraxia), and excessive random movements (catatonic excitement) are consistent with recognized catatonic signs. Therefore this statement reflects a misunderstanding and needs follow-up education.

Question 33

The client has been admitted for 2 days and has been active all day. In group therapy, he smiles and states “I feel great now. Thanks for the help, I’m ready to leave.” The nurse should anticipate which modification to the client’s plan of care?

Accepted Answer

Answer reason: The safest nursing action is to increase observation to detect impulsivity, agitation, elopement risk, or suicidal/homicidal intent that may emerge as energy increases. Discharge planning is premature after only 2 days because symptom improvement must be sustained and safety assessed over time. Decreasing medication is inappropriate without provider evaluation and could worsen symptoms or destabilize the client further. Removing the client from group therapy is not the primary priority; safety assessment and close monitoring are.

Question 34

Which of the following has a gradual onset and is non-reversible?

Accepted Answer

Answer reason: This pattern contrasts with delirium, which has an acute onset, fluctuating course, and is often reversible once the underlying cause is treated. Depression can mimic cognitive impairment (“pseudodementia”) but is potentially reversible with effective therapy. Derealization disorder involves altered perception/experience of reality rather than a progressive cognitive decline and is not classically characterized by irreversible deterioration.

Question 35

Which of the following is not a sign of anorexia nervosa?

Accepted Answer

Answer reason: As nutritional status worsens, clients commonly develop amenorrhea rather than heavy menstrual bleeding. Chronic malnutrition also produces integumentary changes such as brittle nails and lanugo as the body attempts to conserve heat and reflects protein/calorie deficiency. Heavy menses would be atypical in this context and should prompt evaluation for other gynecologic or bleeding-related causes.

Question 36

A depressed client has recently been admitted to the psych unit due to worsening symptoms and suicidal thoughts. The client has been on SSRI’s for years with frequent switching between medications due to lack of therapeutic improvement. What potential treatment plan does the nurse anticipate the physician to order for this client?

Accepted Answer

Answer reason: This presentation suggests treatment-resistant depression with urgent safety risk, where a modality with faster onset than medication changes is preferred. ECT has strong evidence for rapid symptom reduction, including suicidality, and is commonly used when multiple SSRIs have failed. Switching to another SSRI would repeat an ineffective strategy, and tricyclics carry higher toxicity in overdose, which is a major concern in a suicidal patient. Clozapine is primarily for treatment-resistant schizophrenia (and reducing suicide risk in schizophrenia) rather than unipolar depression.

Question 37

A nurse is assessing a client who reports suddenly being unable to see after a traumatic accident, with no physiological cause for the blindness. The client is likely experiencing?

Accepted Answer

Answer reason: Conversion disorder involves neurologic-like symptoms (e.g., blindness, paralysis, seizures) that arise after psychological stress and are not explained by a medical condition. The sudden onset of blindness after trauma with no physiologic basis fits an unconscious stress response expressed as a physical symptom. In contrast, projection attributes one’s unacceptable feelings to others, and rationalization offers logical-sounding explanations to reduce anxiety, neither of which produces sensory loss. Regression is reverting to earlier developmental behaviors, not a sensory deficit.

Question 38

A patient with schizophrenia tells the nurse that he is a spy for the CIA. Which type of symptom is this?

Accepted Answer

Answer reason: Believing one is a spy for the CIA reflects a grandiose/persecutory-type belief rather than a perceptual disturbance. Hallucinations involve sensory perception without an external stimulus (e.g., tactile sensations), and command hallucinations are voices telling the person to act, neither of which is described here. Anhedonia is a negative symptom involving diminished pleasure, which is unrelated to this belief statement.

Question 39

Which of the following causes a change in level of consciousness?

Accepted Answer

Answer reason: It commonly results from underlying medical causes (e.g., infection, hypoxia, metabolic derangements, medication effects) and therefore presents with waxing/waning alertness and impaired ability to focus. Dementia primarily causes chronic, progressive cognitive decline with generally preserved level of consciousness until late stages. Depression and derealization involve mood or perception changes but do not typically produce a fluctuating impairment in consciousness/alertness.

Question 40

The nurse is providing discharge education to a client recently diagnosed with bipolar I disorder. Which statement indicates that the discharge teaching was effective?

Accepted Answer

Answer reason: ” Sleep deprivation and circadian rhythm disruption are common triggers for mania, so teaching focuses on maintaining consistent sleep and daily routines to reduce relapse risk. This statement shows the client understands a key nonpharmacologic strategy for prevention and early stability after discharge. In contrast, lithium is typically long-term maintenance therapy for bipolar I to prevent recurrence rather than a short, time-limited course. Changing the schedule frequently and minimizing concern about caffeine can both undermine sleep and routine, increasing the risk of mood destabilization.

Question 41

A 12-year-old with anorexia nervosa is being discharged today. Her parents are very concerned about taking her home and want to know how to make her eat. What is the best response from the nurse?

Accepted Answer

Answer reason: Anorexia nervosa management at home emphasizes structured, supervised, nonpunitive meals with family support and consistent routines rather than coercion. Regular family dinners provide predictable expectations, reduce secrecy around food, and allow caregivers to observe intake and emotional responses. Involving the child in meal-related tasks supports gradual normalization of eating-related activities and a sense of control without turning food into a power struggle. In contrast, “hiding” high-calorie snacks is deceptive and can increase anxiety, mistrust, and disordered behaviors; education/food logs can be adjuncts but are not as therapeutically foundational as establishing a consistent family meal structure.

Question 42

Anorexia nervosa in adolescence is thought to have an environmental component and the need for the patient to feel in control of something in his/her life. Which type of home environment should the nurse assess for in a client diagnosed with anorexia?

Accepted Answer

Answer reason: A family climate that values appearance, high achievement, and others’ judgments can reinforce distorted body image and restrictive behaviors. This assessment finding aligns with known psychosocial risk patterns seen in adolescents with eating disorders. By contrast, financial stress or an unpredictable household is not the classic environmental association tested for anorexia compared with perfectionistic, image-focused pressures.

Question 43

A nurse is caring for a client who reports feeling that the news anchor on the ward television is speaking directly to them. This is most indicative of which psychological phenomenon?

Accepted Answer

Answer reason: Interpreting a TV news anchor’s general broadcast as a personal message is a classic example of referential thinking progressing to a delusional interpretation. This differs from persecutory delusions, which center on being harmed, targeted, or conspired against rather than being singled out for special messages. Somatic symptom disorder involves distressing physical symptoms, and depersonalization involves feeling detached from oneself, neither of which matches the described belief.

Question 44

A patient with Alzheimer’s disease displays increasing confusion and agitation in the evening. The nurse correctly identifies this as which finding?

Accepted Answer

Answer reason: This phenomenon is associated with reduced environmental cues, fatigue, and disrupted sleep-wake cycles, leading to late-day agitation and disorientation. Delirium tremens is tied to alcohol withdrawal with autonomic hyperactivity and hallucinations, not a predictable evening pattern in dementia. A fugue state involves sudden travel with amnesia for identity, and urosepsis would typically include systemic infection signs (e.g., fever, hypotension), not isolated evening agitation.

Question 45

A patient with schizophrenia says to the nurse “I ran to the fan to see the man holding a pan.” Which type of speech alteration is this patient experiencing?

Accepted Answer

Answer reason: The phrase uses multiple rhyming words (fan/man/pan) that are linked by sound and not by logical content, which is characteristic in schizophrenia. Echolalia would involve repeating another person’s words, which is not present here. Word salad is an incoherent mixture of unrelated words/phrases, whereas this statement is rhythmic and sound-driven rather than nonsensical.

Question 46

A patient with schizophrenia tells the nurse that she hears a voice in her head telling her to run into traffic. Which type of a symptom is this?

Accepted Answer

Answer reason: Hearing a voice directing the patient to run into traffic fits this definition and signals an immediate safety concern that requires prompt assessment of intent and ability to resist the command. A delusion is a fixed false belief rather than a sensory perception, so it does not match “hears a voice.” Anergia refers to decreased energy/avolition (a negative symptom), and echolalia is the repetition of another person’s words, neither of which describes this scenario.

Question 47

In following which is not a psychiatric emergency?

Accepted Answer

Answer reason: Suicide, stupor (possible catatonia), and severely excited behavior can pose immediate risk to self or others and require urgent intervention. Mania alone is not always an emergency unless it escalates to dangerous behavior.

Question 48

A client who is undergoing work-related frustration is shouting and harassing others. What defense mechanism is the client exhibiting?

Accepted Answer

Answer reason: The client’s work frustration is the provoking stressor, but the aggressive behavior is directed toward other people rather than addressing the workplace source. This pattern fits redirected hostility rather than attributing unacceptable feelings to others, which would suggest projection. It is also not rationalization (explaining away behavior with excuses) or regression (reverting to earlier developmental behaviors).

Question 49

Which of the following is not a primary characteristic of borderline personality disorder?

Accepted Answer

Answer reason: Disturbed self-image, intense mood reactivity, and extreme idealization/devaluation are core features that commonly drive impulsive behavior and recurrent crises. Echolalia is the pathological repetition of others’ words and is more characteristic of conditions such as autism spectrum disorder, catatonia, certain neurologic disorders, or severe psychosis rather than personality pathology. Therefore, it is the best choice for what is not a primary characteristic of borderline personality disorder.

Question 50

Which component of the mental status exam is the nurse assessing when noting that a patient is calm and relaxed?

Accepted Answer

Answer reason: Noting that someone is calm and relaxed reflects observable motor activity, posture, facial expression, and general engagement rather than their internal emotional state. Mood is the patient’s sustained internal feeling state and is primarily elicited by asking how they feel. Speech and thought processing would require evaluating rate/volume/content/organization of verbal responses rather than simply observing a relaxed presentation.

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