Question 1

You are caring for an elderly woman who is a practicing Orthodox Judaism. Which meal would you most likely offer this client?

Accepted Answer

Answer reason: Observant Orthodox Jewish dietary laws (kashrut) prohibit pork and prohibit mixing meat with dairy in the same meal. A dairy-based meal with fruit aligns with these restrictions and is broadly acceptable without requiring specific meat preparation or separation. Pork is non-kosher, making that option clearly inappropriate. A meat item served with milk violates the meat-and-dairy separation rule, and a mixed meat dish may be noncompliant depending on kosher certification and preparation.

Question 2

A client has been hospitalized with bipolar disorder, manic episode. The nursing care plan includes the diagnosis "Imbalanced nutrition: less than body requirements." Which of the following meal selections would be best for the client?

Accepted Answer

Answer reason: Finger foods and portable items improve intake while supporting safety and reducing agitation at mealtimes. This meal provides a handheld protein source and easy-to-eat sides, making it more realistic for sustained consumption in mania. A common distractor is a plated entrée meal that requires sitting and utensils, which manic clients are more likely to abandon before eating enough.

Question 3

A client who lives alone had a total laryngectomy for laryngeal cancer 3 months ago. The client has a tracheoesophageal puncture (TEP) to enable speech and tells the nurse, "It's a good thing it's cold outside, so I can keep the hole in my neck covered up with a scarf. I don't know what I'll do when the weather gets warmer." What is the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: This reflects concern about self-concept and how the body looks to self/others rather than a primary physiologic problem. Although a TEP can affect communication, the client is not describing inability to speak or frustration with speech; the focus is concealment and embarrassment. Ineffective coping is broader and would be more appropriate if the client showed maladaptive behaviors or inability to manage daily life beyond the appearance concern. Ineffective self-health maintenance is not supported because no deficits in care of the stoma/TEP or health management are described.

Question 4

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?

Accepted Answer

Answer reason: " Delusions of reference involve the belief that neutral external events (e.g., music, TV, gestures) have special personal meaning directed at the client. Interpreting a song as a secret coded message meant specifically for them is a classic example. In contrast, believing bugs are under the skin reflects tactile hallucinations, and hearing a voice commanding harm reflects auditory command hallucinations. Believing Martians are poisoning the water is a persecutory/bizarre delusion, not a reference delusion.

Question 5

The nurse assesses an 85-year-old client. Which statement by the client requires follow-up?

Accepted Answer

Answer reason: " Social withdrawal in an older adult is a red flag because it increases risk for isolation, depression, and cognitive decline and often reflects an addressable sensory deficit. Marked hearing difficulty that is changing behavior warrants follow-up assessment (hearing screening, evaluation for cerumen, medication effects, or need for amplification) and support to maintain communication and safety. The other statements describe common age-related changes (reduced night vision, decreased stamina, morning stiffness) that are often expected and already paired with an appropriate self-management strategy. The key issue is the functional impact and psychosocial consequence, not the presence of aging changes alone.

Question 6

A client with paranoid schizophrenia is withdrawn and suspicious of others and projects blame. The client's behavior reflects problems in which of the following stages of development identified by Erikson?

Accepted Answer

Answer reason: Prominent suspiciousness, interpersonal distrust, and attributing harmful intent to others are most consistent with an impaired foundation of basic trust. Paranoid schizophrenia commonly features persecutory ideation and projection, which align with pervasive mistrust rather than autonomy/initiative conflicts. Intimacy versus isolation more specifically concerns forming close adult relationships, whereas the core feature emphasized here is distrust and suspicion.

Question 7

A nurse is caring for an older adult client in a long-term care facility. Which of the following findings would alert the nurse to the possibility that the client had developed delirium?

Accepted Answer

Answer reason: A key differentiator from dementia is an altered or fluctuating level of consciousness, often with inattention and disorganized thinking. Gradual memory loss and difficulty with abstract thought are more consistent with chronic neurocognitive disorder (dementia) rather than an acute confusional state. Hopelessness points more toward depression and does not specifically indicate an acute change in consciousness/attention.

Question 8

While assessing a Vietnamese child in the emergency department, the nurse notes erythematous, linear markings on the torso. As the caregiver explains how she put them there to treat fever, nurse Joanna suspects?

Accepted Answer

Answer reason: The key principle is to distinguish culturally based healing practices from non-accidental injury by matching lesion pattern and caregiver history. Cupping typically produces round ecchymotic circles rather than linear marks. Chelation is a treatment for heavy metal poisoning and would not explain superficial linear skin markings.

Question 9

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome?

Accepted Answer

Answer reason: " Dependent personality disorder is characterized by excessive need to be taken care of, leading to submissive/clinging behavior and difficulty making independent decisions. This statement shows increased autonomy and independent problem-solving to meet a need despite lack of usual support, which reflects therapeutic progress. The other options either reinforce reliance on others (planning to stay with cousin when parents leave), focus on self-criticism without adaptive coping, or express gratitude that can signal continued overdependence on the nurse rather than growing self-efficacy. Improvement is best demonstrated by taking independent action in daily functioning.

Question 10

The nurse in labor and delivery provides care for a client who is Muslim and in active labor. The client's labor is long and difficult. Which cultural practice will the nurse expect after the birth?

Accepted Answer

Answer reason: Nursing care incorporates culturally congruent practices when they are safe and do not conflict with medical needs. In many Muslim communities, protective items such as an amulet or a blue stone (used to ward off the “evil eye”) may be used for newborn protection, especially after a difficult labor. The other choices are not typical, broadly recognized Muslim postpartum cultural practices and could reflect individual preference rather than a predictable expectation. Supporting this benign practice promotes trust and respects family beliefs while maintaining newborn safety (e.g., ensuring it is secured and not a choking/strangulation hazard).

Question 11

The nurse is getting a report from the previous shift. The off-going nurse says that the post-stroke client has a flat affect. The on-coming nurse expects which finding on assessment of the client?

Accepted Answer

Answer reason: A client with flat affect may speak normally but show little facial animation and limited emotional responsiveness to social interaction. Not laughing or smiling with visitors matches diminished affective expression. Crying and appearing sad suggests depressed mood rather than flat affect, and the other options describe unrelated physical findings.

Question 12

The nurse is assessing a client with post-traumatic stress disorder (PTSD). Which assessment finding would be expected?

Accepted Answer

Answer reason:  PTSD commonly presents with persistent hyperarousal due to dysregulated stress responses after trauma. This leads to exaggerated startle, constant scanning for danger, irritability, and sleep disturbance, making hypervigilance an expected assessment finding. Delusions of grandeur are more consistent with manic or psychotic disorders rather than PTSD. Flight of ideas and circumstantial speech reflect disorganized or pressured thought processes typically seen in mania or some psychotic-spectrum conditions, not the core PTSD symptom cluster.

Question 13

The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect?

Accepted Answer

Answer reason: Early dementia commonly leads to awareness of cognitive lapses, and a frequent coping response is to minimize or refuse to acknowledge the deficits to protect self-esteem and reduce anxiety. This fits the defense mechanism of denying a reality that is distressing. Projection would involve attributing one’s own unacceptable feelings or problems to others, which is less characteristic of the typical early-dementia presentation. Conversion is the unconscious expression of psychological conflict as neurologic symptoms, which is not the expected pattern here.

Question 14

A staff member states, “I don’t know why Mary is so depressed. She lives in an exclusive part of town and has gorgeous clothes. Her husband seems to care about her very much. She really has it all.” Which of the following should the nurse conclude from the staff member’s statement?

Accepted Answer

Answer reason: Major depression is a clinical mood disorder driven by neurobiologic and psychosocial factors and is not prevented by wealth, relationships, or outward success. The staff member is equating “having it all” with emotional well-being, which reflects misunderstanding and can contribute to stigma and poor support. A nurse should recognize the need for education that depression can occur despite seemingly favorable life circumstances and requires assessment and treatment. Options implying the client has no reason to be depressed or that an accurate assessment was made reflect invalidating assumptions rather than clinical evaluation.

Question 15

A patient in a psychiatric unit is watching the news on the television. She stands up and states that the news anchor is talking directly to her. This is an example of?

Accepted Answer

Answer reason: A delusion of reference is the fixed false belief that neutral events or media messages are specifically directed at oneself. Interpreting a television news anchor as speaking directly to the patient fits this misinterpretation of an external stimulus as personally meaningful. Delusional parasitosis would involve a false belief of being infested with parasites, which is not present here. Persecutory delusions center on being harmed or targeted, and grandiose delusions involve exaggerated self-importance—neither matches the described belief.

Question 16

The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is?

Accepted Answer

Answer reason: Stage III is commonly associated with clear functional decline and agnosia/apraxia, where the person may no longer identify familiar items and has increasing difficulty performing learned tasks. Simple memory loss alone is more characteristic of earlier stages, before significant impairment in recognition and higher cortical processing develops. Night wandering and severe inability to communicate tend to be features of later, more advanced stages when behavioral disturbance and profound language decline predominate.

Question 17

A nursing assistant (NA) comments to the nurse about a recently admitted client. “I think the new admit is just faking being sick. Yesterday we couldn’t get a word out of the client and today the client is talking nonstop.” Which response by the nurse is most appropriate in reflecting empathy for the client?

Accepted Answer

Answer reason: ” Empathy in mental health nursing includes recognizing that behaviors can be symptoms of illness and reframing stigmatizing interpretations into understanding. This response educates the NA that abrupt shifts from withdrawal to pressured speech may reflect a mood disorder rather than malingering, which promotes compassionate, nonjudgmental care. It also helps reduce bias that could lead to dismissive interactions and missed assessment cues. Option 1 reinforces stigma and invalidates the client, while option 2 addresses professionalism but does not address the NA’s judgment about the client’s behavior or foster empathic understanding.

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Mental Health Concepts Practice Test 9

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