PRACTICE QUESTIONS ANSWERS AND RATIONALES · tional pain is an example of a learned, not ... PRACTICE QUESTIONS ANSWERS AND RATIONALES ... that interventions are based on theories

Theory

1. 1. Inability of the ego to intervene when conflict occurs relates to the psychoanalytic,not cognitive, theory of panic disorder development.

2. Abnormal elevations of blood lactate andincreased lactate sensitivity relate to thebiological, not cognitive, theory of panicdisorder development.

3. Increased involvement of the neurochemicalnorepinephrine relates to the biological,not cognitive, theory of panic disorderdevelopment.

4. Distorted thinking patterns that precedemaladaptive behaviors relate to the cogni-tive theory perspective of panic disorderdevelopment.

TEST-TAKING HINT: The test taker should noteimportant words in the question, such as “cogni-tive.” Although all of the answers are potentialcauses of panic disorder development, the onlyanswer that is from a cognitive perspective is “4.”2. An overuse or ineffective use of ego defense

mechanisms, which results in a maladaptiveresponse to anxiety, is an example of thepsychodynamic theory of generalized anxietydisorder development.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker should review the varioustheories related to the development of generalizedanxiety disorder.

3. 1. When the client verbalizes understandingof how the experienced event, individualtraits, and available support systems affecthis or her diagnosis, the client demon-strates a good understanding of the psy-chosocial cause of posttraumatic stressdisorder (PTSD).

2. Avoiding situations as a way to decrease emo-tional pain is an example of a learned, notpsychosocial, cause of PTSD.

3. The release of natural opioids during a trau-matic event is an example of a biological, notpsychosocial, cause of PTSD.

4. Having a negative perception of the worldbecause of a traumatic event is an example ofa cognitive, not psychosocial, cause of PTSD.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker should review the differenttheories as they relate to the causes of different

anxiety disorders, including PTSD. Only “1”describes a psychosocial etiology of PTSD.

4. Sending counselors to a natural disaster site toassist individuals to deal with the devastation is an example of primary prevention. Primaryprevention reduces the incidence of mental disorders, such as posttraumatic stress disorder,within the population by helping individuals to cope more effectively with stress early in the grieving process. Primary prevention isextremely important for individuals who experi-ence any traumatic event, such as a rape, war,hurricane, tornado, or school shooting.

TEST-TAKING HINT: To answer this question cor-rectly, it is necessary to understand the differ-ences between primary, secondary, and tertiaryprevention.

5. 1. The belief that individuals diagnosed withobsessive-compulsive disorder (OCD) haveweak and underdeveloped egos is an explana-tion of OCD etiology from a psychoanalytic,not biological, theory perspective.

2. The belief that obsessive and compulsivebehaviors are a conditioned response to atraumatic event is an explanation of OCD eti-ology from a learning theory, not biologicaltheory, perspective.

3. The belief that regression to the pre-Oedipalanal sadistic phase produces the clinicalsymptoms of OCD is an explanation of OCDetiology from a psychoanalytic, not biological,theory perspective.

4. The belief that abnormalities in variousregions of the brain cause OCD is anexplanation of OCD etiology from a bio-logical theory perspective.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must understand the differ-ent theories of OCD etiology. This question callsfor a biological theory perspective, making “4”the only correct choice.

6. When examining theories of phobia etiology,this situation would be reflective of learningtheory. Some learning theorists believe that fearsare conditioned responses, and they are learnedby imposing rewards for certain behaviors. Inthe instance of phobias, when the individualavoids the phobic object, he or she escapes fear,which is a powerful reward. This client haslearned that avoiding the stimulus of fire elimi-nates fear.

PRACTICE QUESTIONS ANSWERS AND RATIONALES

The correct answer number and rationale for why it is the correct answer are given in boldface blue type.Rationales for why the other answer options are incorrect are also given, but they are not in boldface type.

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TEST-TAKING HINT: To answer this questioncorrectly, the test taker needs to review the different theories of the causation of specificphobias.

7. 1. Offering PRN lorazepam (Ativan) beforegroup is an example of a biological, notintrapersonal, intervention.

2. Attending group with the client is an exampleof an interpersonal, not intrapersonal, inter-vention.

3. Encouraging discussion about fears is anintrapersonal intervention.

4. Role-playing a scenario that may occur is abehavioral, not intrapersonal, intervention.

TEST-TAKING HINT: It is important to understandthat interventions are based on theories of causa-tion. In this question, the test taker needs toknow that intrapersonal theory relates to feelingsor developmental issues. Only “3” deals withclient feelings.

8. 1. Encouraging the client to evaluate the powerof distorted thinking is based on a cognitive,not psychodynamic, perspective.

2. Asking the client to include his or her familyin scheduled therapy sessions is based on aninterpersonal, not psychodynamic, perspective.

3. The nurse discussing the overuse of egodefense mechanisms illustrates a psycho-dynamic approach to address the client’sbehaviors related to panic disorder.

4. Teaching the client the effects of blood lac-tate on anxiety is based on the biological, notpsychodynamic, perspective.

TEST-TAKING HINT: When answering this ques-tion, the test taker must be able to differentiateamong various theoretical perspectives and theirrelated interventions.

9. 1. Ineffective coping R /T punitive superegoreflects an intrapersonal theory of theetiology of obsessive-compulsive disorder(OCD). The punitive superego is aconcept contained in Freud’s psychosocialtheory of personality development.

2. Ineffective coping R /T active avoidancereflects a behavioral, not intrapersonal, theo-ry of the etiology of OCD.

3. Ineffective coping R /T alteration in sero-tonin reflects a biological, not intrapersonal,theory of the etiology of OCD.

4. Ineffective coping R /T classic conditioningreflects a behavioral, not intrapersonal, theo-ry of the etiology of OCD.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to understand thedifferent theories of the etiology of OCD. The

keyword “intrapersonal” should make the testtaker look for a concept inherent in this theory,such as “punitive superego.”

10. 1. Encouraging a client to attend group is aninterpersonal, not intrapersonal, approach totreating survivor’s guilt associated with PTSD.

2. Encouraging expressions of feelingsduring one-to-one interactions with thenurse is an intrapersonal approach tointerventions that treat survivor’s guiltassociated with PTSD.

3. Asking the client to challenge the irrationalbeliefs associated with the event is a cogni-tive, not intrapersonal, intervention to treatsurvivor’s guilt associated with PTSD.

4. Administering regularly scheduled paroxetine(Paxil) is a biological, not intrapersonal,intervention to treat survivor’s guilt associatedwith PTSD.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker needs to differentiatevarious theoretical approaches and which inter-ventions reflect these theories.

Defense Mechanisms

11. 1. Denial is defined as refusing to acknowledgethe existence of a situation or the feelingsassociated with it. No information is presentedin the question that indicates the use of denial.

2. Social isolation is defined as aloneness experi-enced by the individual and perceived asimposed by others and as a negative orthreatening statement. No information ispresented in the question that indicates theclient is experiencing social isolation.

3. Anger is broadly applicable to feelings ofresentful or revengeful displeasure. No infor-mation is presented in the question thatindicates the client is experiencing anger.

4. The client in the question is experiencingsurvivor’s guilt. Survivor’s guilt is a commonsituation that occurs when an individualexperiences a traumatic event in which others died and the individual survived.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to understand com-mon phenomena experienced by individualsdiagnosed with posttraumatic stress disorder andrelate this understanding to the client statementpresented in the question.

12. 1. Suppression, the voluntary blocking from one’sawareness of unpleasant feelings and experi-ences, is not a defense mechanism commonlyused by individuals diagnosed with OCD.

CHAPTER 7 ANXIETY AND SLEEP DISORDERS 141


2. Repression, the involuntary blocking ofunpleasant feelings and experiences fromone’s awareness, is not a defense mechanismcommonly used by individuals diagnosed withOCD.

3. Undoing is a defense mechanism com-monly used by individuals diagnosed withOCD. Undoing is used symbolically tonegate or cancel out an intolerableprevious action or experience. An individ-ual diagnosed with OCD experiencingintolerable anxiety would use the defensemechanism of undoing to undo thisanxiety by substituting obsessions orcompulsions or both. Other commonlyused defense mechanisms are isolation,displacement, and reaction formation.

4. Denial, the refusal to acknowledge theexistence of a real situation or the feelingsassociated with it or both, is not a defensemechanism commonly used by individualsdiagnosed with OCD.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to understand theunderlying reasons for the ritualistic behaviorsused by individuals diagnosed with OCD.

Nursing Process—Assessment

13. 1. When the client reports satisfaction withthe quality of sleep, the client is providingsubjective assessment data. Good sleepersself-define themselves as getting enoughsleep and feeling rested. These individualsfeel refreshed in the morning, have energyfor daily activities, fall asleep quickly, andrarely awaken during the night.

2. The number of hours a client has slept duringthe night is an objective assessment of sleep.Sleep can be observed objectively by notingclosed eyes, snoring sounds, and regularbreathing patterns.

3. The use of a sleep scale objectifies the subjec-tive symptom of sleep quality.

4. The number of midnight awakenings is anobjective assessment of sleep. Even thoughthe client reports this assessment, the numberof midnight awakenings is objective data.

TEST-TAKING HINT: The test taker must look for ananswer choice that meets the criteria of a subjec-tive assessment. Subjective symptoms are symp-toms of internal origin, evident only to the client.

14. 1. Limiting caffeine intake may be important forclients experiencing a sleep disturbance, butthis is an intervention, not an assessment.

2. Teaching the importance of a bedtime routinemay be important for clients experiencing asleep disturbance, but this is an intervention,not an assessment.

3. Keeping the client’s door locked during theday to avoid napping may be important forclients experiencing a sleep disturbance, butthis is an intervention, not an assessment.

4. An important nursing assessment for aclient experiencing a sleep disturbance isto note the client’s baseline sleep patterns.These data allow the nurse to recognizealterations in normal patterns of sleep andto intervene appropriately.

TEST-TAKING HINT: To answer this questioncorrectly, it is important to note the word“assessing.” Answers “1,” “2,” and “3” can beeliminated immediately because they areinterventions, not assessments.

15. Sleep disturbances include hypersomnia andinsomnia.1. Chronic conditions, such as arthritis and

joint and muscle discomfort and pain, rep-resent some of the many reasons why elderly clients are at an increased risk for sleep disturbances.

2. Confusion and wandering as a result ofdementia can be a reason why elderlyclients are at an increased risk for sleepdisturbances.

3. Inactivity and other psychosocialconcerns, such as loneliness or boredom,can be a reason why elderly clients are atan increased risk for sleep disturbances.

4. Increased anxiety is a reason why elderlyclients can be at an increased risk forsleep disturbances.

5. Medications have many side effects,including insomnia, and medications aremetabolized differently in elderly clients.Many elderly clients, because of chronicconditions, experience polypharmacy, and so they are at higher risk for sleepdisturbances.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must understand the differ-ent biological and psychosocial factors that mayinfluence the sleep patterns of elderly clients.

16. Primary insomnia may manifest by a combina-tion of difficulty falling asleep and intermittentwakefulness during sleep.1. Lack of sleep results in daytime irritability.2. Lack of sleep results in problems with

attention and concentration.3. Individuals diagnosed with insomnia may

inappropriately use substances, including

142 PSYCHIATRIC/MENTAL HEALTH NURSING SUCCESS


hypnotics for sleep and stimulants tocounteract fatigue.

4. Nightmares are frightening dreams that occurduring sleep. Because clients diagnosed withinsomnia have trouble sleeping, nightmaresare not a characteristic of this disorder.

5. Sleepwalking is characterized by theperformance of motor activity during sleep, not wakefulness, in which the individ-ual may leave the bed and walk about, dress,go to the bathroom, talk, scream, and evendrive.

TEST-TAKING HINT: The test taker must recognizethe symptoms of insomnia to answer this ques-tion correctly.

17. 1. Parasomnia refers to the unusual or undesir-able behaviors that occur during sleep (e.g.,nightmares, sleep terrors, and sleep walking).Parasomnias are not classified as breathing-related sleep disorders.

2. Hypersomnia refers to excessive sleepiness or seeking excessive amounts of sleep.Hypersomnia is not classified as a breathing-related sleep disorder.

3. Apnea refers to the cessation of breathingduring sleep. To be so classified, theapnea must last for at least 10 seconds andoccur 30 or more times during a 7-hourperiod of sleep. Apnea is classified as abreathing-related sleep disorder.

4. Cataplexy refers to a sudden, brief loss ofmuscle control brought on by strong emotionor emotional response, such as a hearty laugh,excitement, surprise, or anger. Cataplexy isnot classified as a breathing-related sleepdisorder.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker first needs to be familiarwith the terminology related to sleep disordersand then to note what affects breathing patterns.18. The parasomnia of sleep terrors is closely associ-

ated with sleepwalking, and often a night terrorepisode progresses into a sleepwalking episode.Approximately 1% to 6% of children experiencesleep terrors, and the incidence seems to bemore common in boys than in girls. Resolutionusually occurs spontaneously during adoles-cence. If the disorder begins in adulthood, itusually runs a chronic course.1. The client, on awakening, is unable to explain

the nightmare. On awakening in the morning,the client experiences amnesia about theentire episode.

2. The client is not easily awakened after thenight terror. The client is often difficult toawaken or comfort.

3. During a sleep terror, the client doesexperience an abrupt arousal from sleepwith a piercing scream or cry.

4. The client, on awakening during a nightterror, is usually disoriented, not alert andoriented. The client expresses a sense ofintense fear, but cannot recall the dreamepisode.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must understand thecharacteristics associated with sleep terrors.

19. 1. A client diagnosed with posttraumaticstress disorder (PTSD) may have dissocia-tive events in which the client feelsdetached from the situation or feelings.

2. A client diagnosed with PTSD may haveintense fear and feelings of helplessness.

3. A client diagnosed with PTSD has feelings ofdetachment or estrangement toward others,not excessive attachment and dependence.

4. A client diagnosed with PTSD has restricted,not full, range of affect.

5. A client diagnosed with PTSD avoids activ-ities associated with the traumatic event.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must be aware of thedifferent symptoms associated with the diagnosisof PTSD.

20. 1. The degree of ego strength is a part of indi-vidual variables, not part of the recovery envi-ronment. Other variables of the individualinclude effectiveness of coping resources,presence of preexisting psychopathology, out-comes of previous experiences with stress andtrauma, behavioral tendencies (e.g., tempera-ment), current psychosocial developmentalstage, and demographic factors (socioeco-nomic status and education).

2. Availability of social supports is part ofenvironmental variables. Others includecohesiveness and protectiveness of familyand friends, attitudes of society regardingthe experience, and cultural and subcul-tural influences.

3. Severity and duration of the stressor is a vari-able of the traumatic experience, not part ofthe recovery environment. Other variables ofthe traumatic experience include amount ofcontrol over the recurrence, extent of antici-patory preparation, exposure to death, thenumber affected by the life-threatening situa-tion, and location where the traumatic eventwas experienced.

4. Amount of control over the recurrence is avariable of the traumatic experience, not partof the recovery environment.



TEST-TAKING HINT: To answer this questioncorrectly, the test taker needs to understand thefollowing three significant elements in thedevelopment of posttraumatic stress disorder:traumatic experience, individual variables, andenvironmental variables.

21. 1. Recurrent distressing flashbacks are emotional,not behavioral, symptoms of posttraumaticstress disorder (PTSD).

2. Intense fear, helplessness, and horror are cog-nitive, not behavioral, symptoms of PTSD.

3. Diminished participation in significantactivities is a behavioral symptom ofPTSD.

4. Detachment or estrangement from aches areinterpersonal, not behavioral, symptoms ofPTSD.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker should take note of thekeyword “behavioral,” which determines thecorrect answer. All symptoms may be exhibitedin PTSD, but only answer choice “3” is a behav-ioral symptom.

22. 1. A client fearful of spiders is experiencingarachnophobia, not acrophobia.

2. Acrophobia is the fear of heights. An indi-vidual experiencing acrophobia may beunable to fly because of this fear.

3. A client fearful of marriage is experiencinggamophobia, not acrophobia.

4. A client fearful of lightning is experiencingastraphobia, not acrophobia.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to review the defini-tions of specific commonly diagnosed phobias.

23. 1. A client cannot be diagnosed with social phobiawhen under the influence of substances such asmarijuana. It would be unclear if the client isexperiencing the fear because of the mood-altering substance or a true social phobia.

2. Children can be diagnosed with social pho-bias. However, in children, there must be evi-dence of the capacity for age-appropriatesocial relationships with familiar people, andthe anxiety must occur in peer and adultinteractions.

3. If a general medical condition or another men-tal disorder is present, the social phobia mustbe unrelated. If the fear is related to the med-ical condition, the client cannot be diagnosedwith a social phobia.

4. A student who avoids classes because ofthe fear of being scrutinized by othersmeets the criteria for a diagnosis of socialphobia.

TEST-TAKING HINT: The test taker must under-stand the DSM-IV-TR diagnostic criteria forsocial phobia to answer this question correctly.

24. 1. Fear of dying is an affective, not physical,symptom of a panic attack.

2. Sweating and palpitations are physicalsymptoms of a panic attack.

3. Depersonalization is an alteration in the per-ception or experience of the self, so that thefeeling of one’s own reality is temporarilylost. Depersonalization is a cognitive, notphysical, symptom of a panic attack.

4. Restlessness and pacing are behavioral, notphysical, symptoms of a panic attack.

TEST-TAKING HINT: The test taker must noteimportant words in the question, such as “physi-cal symptoms.” Although all the answers areactual symptoms a client experiences during apanic attack, only “2” is a physical symptom.

25. 1. Using excessive hand washing to relieveanxiety is a behavioral symptom exhibitedby clients diagnosed with obsessive-compulsive disorder (OCD).

2. The verbalization of anxiety is not classifiedas a behavioral symptom of OCD.

3. Using breathing techniques to decreaseanxiety is a behavioral intervention, not abehavioral symptom.

4. Excessive sweating and increased pulse arebiological, not behavioral, symptoms of OCD.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must be able to differentiatevarious classes of symptoms exhibited by clientsdiagnosed with OCD. The keyword “behavioral”determines the correct answer to this question.

26. 1. Although the client may be exhibiting signsand symptoms of an exacerbation of general-ized anxiety disorder, the nurse cannotassume this to be true before a thoroughassessment is done.

2. Although the client may be experiencing anunderlying medical condition that is causingthe anxiety, the nurse cannot assume this tobe true before a thorough assessment is done.

3. Physical problems should be ruled outbefore determining a psychological causefor this client’s symptoms.

4. Although the client may need an anxiolyticdosage increase, the nurse cannot assume thisto be true before a thorough physical assess-ment is done.

TEST-TAKING HINT: The test taker needs toremember that although a client may have ahistory of a psychiatric illness, a complete, thor-ough evaluation must be done before assuming



exhibited symptoms are related to the psychiatricdiagnosis. Many medical conditions generateanxiety as a symptom.

27. 1. Chronic obstructive pulmonary diseasecauses shortness of breath. Air deprivationcauses anxiety, sometimes to the point ofpanic.

2. Hyperthyroidism (Graves’s disease)involves excess stimulation of the sympa-thetic nervous system and excessive levelsof thyroxine. Anxiety is one of severalsymptoms brought on by these increases.

3. Hypertension is an often asymptomatic disor-der characterized by persistently elevatedblood pressure. Hypertension may be causedby anxiety, in contrast to anxiety being theresult of hypertension.

4. Diverticulosis results from the outpocketingof the colon. Unless these pockets becomeinflamed, diverticulosis is generally asympto-matic.

5. Marked irritability and anxiety are someof the many symptoms associated withhypoglycemia.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to understand thatanxiety is manifested by physiological responses.

28. 1. A client cannot be diagnosed with an anxietydisorder if anxiety is experienced in only onearea of functioning.

2. Although anxiety does need to be experiencedfor a period of time before being diagnosed asan anxiety disorder, this answer states “one”area of functioning and so is incorrect.

3. For a client to be diagnosed with an anxi-ety disorder, the client must experiencesymptoms that interfere in a minimum oftwo areas, such as social, occupational, orother important functioning. These symp-toms must be experienced for durations of6 months or longer.

4. A client needs to experience high levels ofanxiety that affect functioning in a minimumof two areas of life, and these must have dura-tions of 6 months or longer.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must understand thatspecific symptoms must be exhibited and specifictimeframes achieved for clients to be diagnosedwith anxiety disorders.

29. 1. A client diagnosed with generalized anxietydisorder (GAD) would experience exces-sive worry about items difficult to control.

2. A client diagnosed with GAD would expe-rience muscle tension.

3. A client diagnosed with GAD would experi-ence insomnia, not hypersomnia. Sleep dis-turbances would include difficulty fallingasleep, difficulty staying asleep, and restlesssleep.

4. A client diagnosed with GAD would be easily fatigued and not experience excessiveamounts of energy.

5. A client diagnosed with GAD wouldexperience an increased startle reflex andtension, causing feelings of being “keyedup” or being “on edge.”

TEST-TAKING HINT: To answer this question cor-rectly, the test taker would need to recognize thesigns and symptoms of GAD.30. 1. Compulsive behaviors that occupy many hours

per day would be a behavioral, not cognitive,symptom experienced by clients diagnosedwith obsessive-compulsive disorder (OCD).

2. Excessive worrying about germs and ill-ness is a cognitive symptom experiencedby clients diagnosed with OCD.

3. Comorbid abuse of alcohol to decrease anxi-ety would be a behavioral, not cognitive,symptom experienced by clients diagnosedwith OCD.

4. Excessive sweating and increased bloodpressure and pulse are physiological, notcognitive, symptoms experienced by clientsdiagnosed with OCD.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must note the keyword“cognitive.” Only “2” is a cognitive symptom.

Nursing Process—Diagnosis

31. Hypersomnia, or somnolence, can be defined asexcessive sleepiness or seeking excessive amountsof sleep. Excessive sleepiness interferes withattention, concentration, memory, and produc-tivity. It also can lead to disruption in social andfamily relationships. Depression is a commonside effect of hypersomnia, as are substance-related disorders.1. Verbalizations of worthlessness may

indicate that this client is experiencingsuicidal ideations. After assessing suiciderisk further, the risk for suicide should beprioritized.

2. Social isolation R /T sleepiness would be anappropriate nursing diagnosis for a clientdiagnosed with hypersomnia because oflimited contact with others as a result ofincreased sleep. Compared with the othernursing diagnoses presented, however, thisdiagnosis would not take priority.



3. Self-care deficit R /T increased need for sleepAEB being unable to bathe without assistancewould be an appropriate nursing diagnosis fora client diagnosed with hypersomnia becauseof the limited energy for bathing related toincreased sleepiness. Compared with theother nursing diagnoses presented, however,this diagnosis would not take priority.

4. Chronic low self-esteem R /T inability tofunction AEB the statement, “I feel worth-less,” is an appropriate nursing diagnosis for a client diagnosed with hypersomnia.Compared with the other nursing diagnosespresented, however, this diagnosis would nottake priority.

TEST-TAKING HINT: All the nursing diagnosespresented document problems associated withhypersomnia. Because the nurse always priori-tizes safety, the nursing diagnosis of risk forsuicide takes precedence.

32. 1. Although posttrauma syndrome is an appro-priate nursing diagnosis for this client, it isnot the priority nursing diagnosis at this time.

2. Although social isolation is an appropriatenursing diagnosis for this client, it is not thepriority nursing diagnosis at this time.

3. Although ineffective coping may be an appro-priate nursing diagnosis for clients diagnosedwith posttraumatic stress disorder, there is noinformation in the question to suggestalcohol use.

4. Risk for injury is the priority nursingdiagnosis for this client. In the question,the client is exhibiting recurrent flash-backs, nightmares, and sleep deprivationthat can cause exhaustion and lead toinjury. It is important for the nurse toprioritize the nursing diagnosis thataddresses safety.

TEST-TAKING HINT: When the question asks for apriority, it is important for the test taker tounderstand that all answer choices may be appro-priate statements. Client safety always should beprioritized.

33. 1. According to the North AmericanNursing Diagnosis Association (NANDA),the nursing diagnosis format mustcontain three essential components:(1) identification of the health problem,(2) presentation of the etiology (or cause)of the problem, and (3) description of acluster of signs and symptoms known as“defining characteristics.” The correctanswer, “1,” contains all three compo-nents in the correct order: health

problem/NANDA stem (social isolation);etiology/cause, or R /T (fear of germs);and signs and symptoms, or AEB (refusingto leave home for the past year). Becausethis client has been unable to leave homefor a year as a result of fear of germs, theclient’s behaviors meet the defining char-acteristics of social isolation.

2. Obsessive-compulsive disorder is a medicaldiagnosis and cannot be used in any compo-nent of the nursing diagnosis format. Nursingdiagnoses are functional client problems thatfall within the scope of nursing practice. Alsomissing from this nursing diagnosis are thesigns and symptoms, or AEB, component ofthe problem.

3. The etiology (R /T) and signs and symptoms(AEB) are out of order in this nursing diag-nostic statement.

4. The inability to leave home is a sign or symp-tom, which is the third component of thenursing diagnosis format (AEB) not the causeof the problem (R /T statement).

TEST-TAKING HINT: To answer this questioncorrectly, the test taker needs to know thecomponents of a correctly stated nursingdiagnosis and the order in which thesecomponents are written.

34. 1. Although ineffective breathing patterns would be an appropriate nursing diagnosisduring a panic attack, the client in the questionis not experiencing a panic attack, and so thisnursing diagnosis is inappropriate at this time.

2. Although impaired spontaneous ventilationwould be an appropriate nursing diagnosisduring a panic attack, the client in the questionis not experiencing a panic attack, and so thisnursing diagnosis is inappropriate at this time.

3. Social isolation is seen frequently withindividuals diagnosed with panic attacks.The client in the question expresses antic-ipatory fear of unexpected attacks, whichaffects the client’s ability to interact withothers.

4. Nothing in the question indicates that theclient has a knowledge deficit related totriggers for panic attacks. The client in the question is expressing fear as it relates to the unpredictability of panic attacks.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must link the behaviorspresented in the question with the nursingdiagnosis that is reflective of these behaviors.The test taker must remember the importance oftime-wise interventions. Nursing interventionsdiffer according to the degree of anxiety the



client is experiencing. If the client were currentlyexperiencing a panic attack, other interventionswould be appropriate.

35. 1. Anxiety is the underlying cause of thediagnosis of obsessive compulsive disorder(OCD), therefore, anxiety R/T obsessivethoughts is the priority nursing diagnosisfor the client newly admitted for thetreatment of this disorder.

2. Powerlessness R /T ritualistic behaviors is anappropriate nursing diagnosis for a clientdiagnosed with OCD; however, for the clientto begin working on feelings of powerlessness,the level of anxiety must be decreased first.

3. Fear R /T a traumatic event AEB stimulusavoidance would be an appropriate nursingdiagnosis for a client diagnosed with post-traumatic stress disorder, not for a clientdiagnosed with OCD.

4. Social isolation R /T increased levels of anxi-ety is an appropriate diagnosis for a clientdiagnosed with OCD; however, anxiety mustbe decreased before the client can work onsocializing.

TEST-TAKING HINT: When the question is askingfor a priority, the test taker should considerwhich client problem would need to beaddressed before any other problem can beexplored. When anxiety is decreased, social isola-tion should improve, and feelings about power-lessness can be expressed.

36. 1. Because safety is always a priority, and thisclient is expressing suicidal ideations, hope-lessness, although appropriate for a clientdiagnosed with generalized anxiety disorder(GAD), would not be the priority nursingdiagnosis at this time.

2. Because safety is always a priority, and thisclient is expressing suicidal ideations, ineffec-tive coping, although appropriate for a clientdiagnosed with GAD, would not be the prior-ity nursing diagnosis at this time.

3. Because safety is always a priority, and thisclient is expressing suicidal ideations, anxiety,although appropriate for a client diagnosedwith GAD, would not be the priority nursingdiagnosis at this time.

4. Because the client is expressing suicidalideations, the nursing diagnosis of risk forsuicide takes priority at this time. Clientsafety is prioritized over all other clientproblems.

TEST-TAKING HINT: When looking for a prioritynursing diagnosis, the test taker always must pri-oritize client safety. Even if other problems exist,client safety must be ensured.

Nursing Process—Planning

37. 1. Although the nurse may want the client touse one coping skill before bedtime to assistin falling asleep, there is no timeframe on thisoutcome, and it is not measurable.

2. The outcome of being able to sleep 6 to 8 hours a night and report a feeling of being rested has no timeframe and is notmeasurable.

3. The client’s being able to ask for pre-scribed PRN medication to assist withfalling asleep by day 2 is a short-term out-come that is specific, has a timeframe, andrelates to the stated nursing diagnosis.

4. Although the nurse may want the client toverbalize a decreased level of anxiety, thisoutcome does not have a timeframe and isnot measurable.

TEST-TAKING HINT: When given a nursingdiagnosis in the question, the test taker shouldchoose the outcome that directly relates to theclient’s specific problem. If a client had a nursingdiagnosis of disturbed sleep patterns R / Tfrequent naps during the day, the short-termoutcome for this client may be “the client willstay in the milieu for all scheduled groups by day2.” Staying in the milieu would assist the client inavoiding napping, which is the cause of thisclient’s problem.

38. 1. It is a realistic expectation for a client whocopes with previous trauma by abusingalcohol to recognize the triggers that pre-cipitate this behavior. This outcomeshould be developed mutually early intreatment.

2. Attending follow-up weekly therapy sessionsafter discharge is a long-term, not short-term,outcome.

3. Expecting the client to refrain from self-blame regarding the rape by day 2 would bean unrealistic outcome. Clients who experi-ence traumatic events need extensive out-patient therapy.

4. Being free from injury does not relate to thenursing diagnosis of ineffective coping.

TEST-TAKING HINT: It is important to relate out-comes to the stated nursing diagnosis. In thisquestion, the test taker should choose an answerthat relates to the nursing diagnosis of ineffectivecoping. Answer “4” can be eliminated immedi-ately because it does not assist the client in cop-ing more effectively. Also, the test taker mustnote important words, such as “short-term.”Answer “2” can be eliminated immediatelybecause it is a long-term outcome.



39. 1. A client diagnosed with posttraumatic stressdisorder experiencing acute flashbacks wouldneed special treatment. An inexperiencedagency nurse may find this situation over-whelming.

2. A client diagnosed with generalized anxietydisorder beginning benzodiazepine therapyfor the first time may have specific questionsabout the disease process or prescribedmedication. An inexperienced agency nursemay be unfamiliar with client teaching needs.

3. A client admitted 4 days ago with a diag-nosis of algophobia, fear of pain, would bean appropriate assignment for the agencynurse. Of the clients presented, this clientwould pose the least challenge to a nurseunfamiliar with psychiatric clients.

4. A client with obsessive-compulsive disorderwould need to be allowed to use his or herritualistic behaviors to control anxiety to amanageable level. An inexperienced agencynurse may not fully understand client behav-iors that reflect the diagnosis of obsessive-compulsive disorder and may intervene inap-propriately.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to recognize the com-plexity of psychiatric diagnoses and understand theramifications of potentially inappropriate nursinginterventions by inexperienced staff members.

40. 1. Expecting the client to participate in a set number of group activities by day 4directly relates to the stated nursing diag-nosis of social isolation and is a measura-ble outcome that includes a timeframe.

2. Although the nurse may want the client touse relaxation techniques to decrease anxiety,this outcome does not have a timeframe andis not measurable.

3. Having the client verbalize one positiveattribute about self by discharge relates to thenursing diagnosis of low self-esteem, notsocial isolation.

4. Buspirone (BuSpar) is not used on a PRNbasis, and so this is an inappropriate outcomefor this client.

TEST-TAKING HINT: To express an appropriateoutcome, the statement must be related to thestated problem, be measurable and attainable,and have a timeframe. The test taker can elimi-nate “2” immediately because there is no time-frame, and then “3” because it does not relate tothe stated problem.

41. 1. Remaining safe throughout the durationof the panic attack is the priority outcomefor the client.

2. Although a decreased anxiety level is a desiredoutcome for a client experiencing panic, thisoutcome is not measurable because it con-tains no timeframe.

3. Although the use of coping mechanisms todecrease anxiety is a desired outcome, thisoutcome is not measurable because it con-tains no timeframe.

4. The verbalization of the positive effects ofexercise is a desired outcome, and it containsa timeframe that is measurable. This wouldbe an unrealistic outcome, however, for aclient experiencing a panic attack.

TEST-TAKING HINT: All outcomes must be appro-priate for the situation described in the question.In the question, the client is experiencing a panicattack; having the client verbalize the positiveeffects of exercise would be inappropriate. All out-comes must be client-centered, specific, realistic,positive, and measurable, and contain a timeframe.

42. 1. A client newly admitted with a panic attackhistory does not command the immediateattention of the nurse. If the client presentswith signs and symptoms of panic, the nurse’spriority would then shift to this client.

2. The nurse would assess a client experiencingflashbacks during the night, but this assess-ment would not take priority at this time overthe other clients described.

3. A client pacing the halls and experienc-ing an increase in anxiety commandsimmediate assessment. If the nurse doesnot take action on this assessment, thereis a potential for client injury to self orothers.

4. A client with generalized anxiety disorderawaiting discharge does not command theimmediate attention of the nurse. To meetthe criteria for discharge, this client should bein stable mental condition.

TEST-TAKING HINT: When the nurse is prioritizingclient assessments, it is important to note whichclient might be a safety risk. When asked to pri-oritize, the test taker must review all the situa-tions presented before deciding which one toaddress first.

43. 1. It is unrealistic to expect the client to use athought-stopping technique totally to elimi-nate obsessive or compulsive behaviors by day4 of treatment.

2. It is unrealistic for clients diagnosed withobsessive-compulsive disorder to abruptlystop obsessive or compulsive behaviors.

3. It is desirable for the client to seek assistancefrom the staff to decrease the amount ofobsessive or compulsive behaviors. However,



this outcome should be prioritized earlierthan day 4 of treatment.

4. By day 4, it would be realistic to expectthe client to use one relaxation techniqueto decrease obsessive or compulsivebehaviors. This would be the currentpriority outcome.

TEST-TAKING HINT: The test taker must recog-nize the importance of time-wise interventionswhen establishing outcomes. In the case ofclients diagnosed with obsessive-compulsivedisorder, expectations on admission vary greatly from outcomes developed closer to discharge.

44. 1. The client’s being able to intervene beforereaching panic levels of anxiety by dis-charge is measurable, relates to the statednursing diagnosis, has a timeframe, and isan appropriate short-term outcome forthis client.

2. The “verbalization of decreased levels ofanxiety” in this outcome is neither specificnor measurable. Instead of a general“decrease” in anxiety, the use of an anxiety scale would make this outcomemeasurable.

3. The client’s taking control of life situations byeffectively using problem-solving methodsrelates to the stated nursing diagnosis; how-ever, it does not have a timeframe and so isnot measurable.

4. The client’s being able to participate vol-untarily in group therapy activities is a short-term outcome; however, this outcome doesnot relate to the stated nursing diagnosis.

TEST-TAKING HINT: When evaluating outcomes,the test taker must make sure that the outcomeis specific to the client’s need, is realistic, ismeasurable, and contains a reasonable time-frame. If any of these components is missing, the outcome is incorrectly written and can beeliminated.

Nursing Process—Intervention

45. The parasomnia of nightmare disorder is diag-nosed when there is a repeated occurrence offrightening dreams that interfere with social oroccupational functioning. Nightmares are com-mon between the ages of 3 and 6 years, andmost children outgrow the phenomenon. Theindividual is usually fully alert on awakeningfrom the nightmare and, because of the linger-ing fear or anxiety, may have difficulty returningto sleep.

1. Family stress can occur as the result ofrepeated client nightmares. This stresswithin the family may exacerbate theclient’s problem and hamper any effectivetreatment. Involving the family in therapyto relieve obvious stress would be anappropriate intervention to assist in thetreatment of clients diagnosed with anightmare disorder.

2. Phototherapy to assist clients to adapt tochanges in sleep would be an appropriateintervention for clients diagnosed with circa-dian rhythm sleep disorders, not nightmaredisorder. Phototherapy, or “bright light”therapy, has been shown to be effective intreating the circadian rhythm sleep disordersof delayed sleep phase disorder and jet lag.

3. Administering medications such astricyclic antidepressants or low-dosebenzodiazepines or both is an appropriateintervention for clients diagnosed with aparasomnia disorder, such as a nightmaredisorder.

4. Giving central nervous system stimulants,such as amphetamines, would be an appropri-ate intervention for clients diagnosed withhypersomnia, not a nightmare disorder.

5. Relaxation therapy, such as meditationand deep breathing techniques, would beappropriate for clients diagnosed with anightmare disorder to assist in falling backto sleep after the nightmare occurs.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must be able first to under-stand the manifestation of a nightmare disorderand then to choose the interventions that wouldaddress these manifestations effectively.

46. Sleepwalking is considered a parasomnia.Sleepwalking is characterized by the performanceof motor activity during sleep in which the indi-vidual may leave the bed and walk about, dress,go to the bathroom, talk, scream, or even drive.1. Equipping the bed with an alarm that acti-

vates when the bed is exited is a prioritynursing intervention. During a sleepwalk-ing episode, the client is at increased riskfor injury, and interventions must addresssafety.

2. Discouraging strenuous exercise before bed-time is an appropriate intervention to pro-mote sleep; however, this intervention doesnot take priority over safety.

3. Limiting caffeine-containing substances within4 hours of bedtime is an appropriate inter-vention to promote sleep; however, this inter-vention does not take priority over safety.



4. Encouraging activities that prepare one forsleep, such as soft music, is an appropriateintervention to promote sleep; however, this intervention does not take priority oversafety.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must understand that aclient experiencing sleepwalking is at increasedrisk for injury. An intervention that addressessafety concerns must be prioritized.

47. 1. During a flashback, the client is experi-encing severe-to-panic levels of anxiety;the priority nursing intervention is tomaintain and reassure the client of his orher safety and security. The client’s anxi-ety needs to decrease before other inter-ventions are attempted.

2. Encouraging the client to express feelingsduring a flashback would only increase theclient’s level of anxiety. The client’s anxietylevel needs to decrease to a mild or moderatelevel before the nurse encourages the client toexpress feelings.

3. Although the nurse may want to decreaseexternal stimuli in an attempt to reduce theclient’s anxiety, ensuring safety and securitytakes priority.

4. It is important for the nurse to be nonjudg-mental and use a matter-of-fact approachwhen dealing with a client experiencing aflashback. However, because this client isexperiencing a severe-to-panic level of anxi-ety, safety is the priority.

TEST-TAKING HINT: It is important to understandtime-wise interventions when dealing with indi-viduals experiencing anxiety. When the clientexperiences severe-to-panic levels of anxiety dur-ing flashbacks, the nurse needs to maintain safetyand security until the client’s level of anxiety hasdecreased.

48. 1. If a client is being admitted for panic attacksbecause of feeling hopeless and helpless, theclient is seeking help; elopement precautionsare not yet necessary. If behaviors indicatethat the client is a danger to self or others,and the client has intentions of leaving theunit, treatment team discussions of elopementprecautions are indicated.

2. Any client who is exhibiting hopelessnessor helplessness needs to be monitoredclosely for suicide intentions.

3. There is no information in the question that supports the need for homicideprecautions.

4. There is no information in the question thatsupports the need for fall precautions.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker should note the words“hopelessness” and “helplessness,” which wouldbe indications of suicidal ideations that warrantsuicide precautions.

49. 1. The nurse would include, not notify, theclient when making decisions to limitcompulsive behaviors. To be successful, theclient and the treatment team must beinvolved with the development of the plan of care.

2. It is important for the client to learn tech-niques to reduce overall levels of anxietyto decrease the need for compulsivebehaviors. The teaching of these tech-niques should begin by day 4.

3. By day 4, the nurse, with the client’s input,should begin setting limits on the compulsivebehaviors.

4. The client, not the nurse, should say theword “stop” as a technique to limit obsessivethoughts and behaviors.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must understand that nurs-ing interventions should be based on timeframesappropriate to the expressed symptoms andseverity of the client’s disorder. The length ofhospitalization also must be considered in plan-ning these interventions. The average stay on anin-patient psychiatric unit is 5 to 7 days.

50. 1. When a client is newly admitted, it isimportant for the nurse to assess pastcoping mechanisms and their effects onanxiety. Assessment is the first step in thenursing process, and this informationneeds to be gathered to interveneeffectively.

2. Allowing time for the client to completecompulsions is important for a client whois newly admitted. If compulsions are lim-ited, anxiety levels increase. If the clienthad been hospitalized for a while, then,with the client’s input, limits would be seton the compulsive behaviors.

3. The nurse would set limits on ritualisticbehaviors, with the client’s input, later in thetreatment process, not when a client is newlyadmitted.

4. A newly admitted client who is exhibitingcompulsions is experiencing a high level ofanxiety. To present the impact of these com-pulsions on daily living would be inappropri-ate at this time and may lead to furtherincreases in anxiety. Clients diagnosed withobsessive-compulsive disorder are aware thattheir compulsions are “different.”



5. It is important for the nurse to allow theclient to express his or her feelings aboutthe obsessions and compulsions. Thisassessment of feelings should begin atadmission.

TEST-TAKING HINT: It is important for the testtaker to note the words “newly admitted” in thequestion. The nursing interventions implement-ed vary and are based on length of stay on theunit, along with client’s insight into his or herdisorder. For clients with obsessive-compulsivedisorder, it is important to understand that thecompulsions are used to decrease anxiety. If thecompulsions are limited, anxiety increases. Also,the test taker must remember that during treat-ment it is imperative that the treatment teamincludes the client in decisions related to anylimitation of compulsive behaviors.

51. 1. The nurse should recognize the state-ment, “I can’t do this anymore,” asevidence of hopelessness and assess fur-ther the potential for suicidal ideations.

2. Removing all potentially harmful objectsfrom the milieu can be an appropriate inter-vention, but only after the severity of clientrisk is determined. This assessment is criticalfor the nurse to intervene appropriately andin a timely manner.

3. Placing the client on a one-to-one observa-tion status can be an appropriate intervention,but only after the severity of client risk isdetermined. This assessment is critical for thenurse to intervene appropriately and in atimely manner.

4. Although it is important for the client toverbalize feelings, this does not take priority atthis time. Suicidal risk needs to be determinedto ensure client safety by implementation ofappropriate and timely nursing interventions.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker should apply the nursingprocess. Assessment is the first step of this process.The nurse initially must assess a situation beforedetermining appropriate nursing interventions.

52. 1. Although it is important to teach the clientrelaxation techniques, this is not the currentpriority. The client has expressed suicidalideations, and the priority is to assess the sui-cide plan further.

2. It is important for the nurse to ask theclient about a potential plan for suicide tointervene in a timely manner. Clients whohave developed suicide plans are at higherrisk than clients who may have vague sui-cidal thoughts.

3. The nurse may want to call the physician toobtain a PRN order for anxiolytic medica-tions; however, a thorough physical evaluationand further assessment of suicidal ideationsneed to occur before calling the physician.

4. It is important for the client to participate ingroup activities. However, the nurse’s firstpriority is assessing suicidal ideations anddeveloping a plan to intervene quickly andappropriately to maintain client safety.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must understand theimportance of assessing the plan for suicide.Interventions would differ depending on theclient’s plan. The intervention for a plan to use a gun at home would differ from anintervention for a plan to hang oneself duringhospitalization.

Nursing Process—Evaluation

53. 1. Although the nurse would like the client toexpress feelings about the experiencednightmares, this statement does not relate to the nursing diagnosis of disturbed sleeppatterns.

2. Although the client requests the prescribedtrazodone (Desyrel) to assist with fallingasleep, there is no assessment information toindicate that this medication has resolved thesleep pattern problem.

3. The client’s feeling rested on awakeningand denying nightmares are the evaluationdata needed to support the fact that thenursing diagnosis of disturbed sleep pat-terns R/T nightmares has been resolved.

4. When the client avoids daytime napping, theclient has employed a strategy to enhancenighttime sleeping. However, this is not eval-uation information that indicates the dis-turbed sleep problem has been resolved.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to discern evaluationdata that indicate problem resolution. Answers“1,” “2,” and “4” all are interventions to assist inresolving the stated nursing diagnosis, not evalu-ation data that indicate problem resolution.

54. 1. It is impossible for clients to eliminate anxietyfrom daily life. Mild anxiety is beneficial andnecessary to completing tasks of daily living.

2. Optimally, a client should be able to performactivities of daily living independently by dis-charge; however, this client action does notindicate successful teaching about breathingtechniques.



3. It is important that a client recognizes signsand symptoms of escalating anxiety, but thisclient action does not indicate successfulteaching about breathing techniques.

4. A client’s ability to maintain an anxietylevel of 3/10 without medications indi-cates that the client is using breathingtechniques successfully to reduce anxiety.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker should understand thatanxiety cannot be eliminated from life. Thisunderstanding would eliminate “1” immediately.

55. 1. This statement is an indication that thecognitive intervention was successful. Byremembering that panic attacks are self-limiting, the client is applying theinformation gained from the nurse’s cognitive intervention.

2. This statement is an indication that a behav-ioral, not cognitive, intervention was imple-mented by the nurse. From a behavioralperspective, the nurse has taught this clientthat exercise can decrease anxiety.

3. This statement is an indication that the nurseimplemented a biological, not cognitive,intervention. From a biological perspective,the nurse has taught this client that anxiolyticmedication can decrease anxiety.

4. This statement is an indication that thenurse implemented an interpersonal, notcognitive, intervention. From an interper-sonal perspective, the nurse has taught thisclient that a social support system candecrease anxiety.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker needs to understandwhich interventions support which theories ofcausation. When looking for a “cognitive” inter-vention, the test taker must remember that thetheory involves thought processes.

Psychopharmacology

56. 1. Clonidine hydrochloride (Catapres) isused in the treatment of panic disordersand generalized anxiety disorder.

2. Fluvoxamine maleate (Luvox) is used inthe treatment of obsessive-compulsivedisorder.

3. Buspirone (BuSpar) is used in the treat-ment of panic disorders and generalizedanxiety disorders.

4. Alprazolam (Xanax), a benzodiazepine, isused for the short-term treatment of anxi-ety disorders.

5. Haloperidol (Haldol) is an antipsychotic usedto treat thought disorders, not anxietydisorders.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker needs to understand thatmany medications are used off-label to treat anx-iety disorders.

57. The client can receive 4 PRN doses.Medications are given four times in a 24-hourperiod when the order reads q6h: 1.5 mg ! 4 "6 mg. The test taker must factor in 2 mg bid "4 mg. These two dosages together add up to 10 mg, the maximum daily dose of alprazolam(Xanax), and so the client can receive all 4 PRNdoses.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must recognize that the tim-ing of standing medication may affect the deci-sion-making process related to administration ofPRN medications. In this case, the client wouldbe able to receive all possible doses of PRN med-ication because the standing and PRN orderedmedications together do not exceed the maxi-mum daily dose.

58. Buspirone (BuSpar) is an antianxiety medicationthat does not depress the central nervous systemthe way benzodiazepines do. Although its actionis unknown, the drug is believed to produce thedesired effects through interactions with sero-tonin, dopamine, and other neurotransmitterreceptors.1. Alcohol consumption is contraindicated while

taking any psychotropic medication; however,buspirone (BuSpar) does not depress the cen-tral nervous system, and so there is no addi-tive effect.

2. It is important to teach the client that theonset of action for buspirone (BuSpar) is 2 to 3 weeks. Often the nurse may see abenzodiazepine, such as clonazepam,prescribed because of its quick onset ofeffect, until the buspirone begins working.

3. Buspirone (BuSpar) is not effective in PRN dosing because of the length of time ittakes to begin working. Benzodiazepines havea quick onset of effect and are used PRN.

4. No current lab tests monitor buspirone(BuSpar) toxicity.

TEST-TAKING HINT: To answer this question cor-rectly, the test taker must understand that bus-pirone (BuSpar) has a delayed onset of action,which can affect medication compliance. If theeffects of the medication are delayed, the client islikely to stop taking the medication. Teachingabout delayed onset is an important nursingintervention.



59. 1.5 tablets.

X tab!

1 tab30 mg 20 mg

20x ! 30 x ! 1.5 tabs

TEST-TAKING HINT: The test taker should set upthe ratio and proportion problem based on thenumber of milligrams contained in 1 tablet andsolve this problem by cross multiplication andsolving for “X” by division.

60. This client should receive 2 PRN doses. The testtaker must recognize that medications are giventhree times in a 24-hour period when the orderreads q8h: 1 mg " 3 ! 3 mg. The test taker

must factor in the 0.5 mg qid ! 2 mg. These two dosages together add up to 5 mg, 1 mg above the maximum daily dose oflorazepam (Ativan). The client would be able toreceive only two of the three PRN doses oflorazepam.

TEST-TAKING HINT: To answer this questioncorrectly, the test taker must recognize that thetiming of standing medication may affect thedecision-making process related to administra-tion of PRN medications. In this case, althoughthe PRN medication is ordered q8h, and couldbe given three times, the standing medicationdosage limits the PRN to two doses, each at least8 hours apart.



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PRACTICE QUESTIONS ANSWERS AND RATIONALES · tional pain is an example of a learned, not ... PRACTICE QUESTIONS ANSWERS AND RATIONALES ... that interventions are based on theories