NP5 Nursing Board Exam November Answer Key 'Nursing

Care of Client with Physiological and Psychosocial

Alteration'
100 Nursing Board Exam test questions of November 2008 Nurse Licensure Examination (NLE)
Nursing Practice V – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 2 Board Exam test questions 51 - 100

Situation 9: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide
related to illness.

51. The nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse
do?
A. Search the client’s belongings and room carefully for items that could be used to attempt suicide.
B. Express trust that the client won’t cause self-harm while in the facility.
C. Respect the client’s privacy by not searching any belongings
D. Remind all staff members to check on the client frequently

52. In planning activities for the depressed client, especially during the early stages of hospitalization, which of the
following plan is best?
A. Provide an activity that is quiet and solitary to avoid increased fatigue such as working on a puzzle and reading a
book.
B. Plan nothing until the client asks to participate in the milieu
C. Offer the client a menu of daily activities and ask the client to participate in all of them
D. Provide a structured daily program of activities and encourage the client to participate

53. A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health
unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals
specifically with the clients:
A. Disturbed thought process
B. Self Care Deficit
C. Imbalanced Nutrition
D. Deficient Knowledge

54. The client is taking a Tricyclic anti depressant. Which of the following is an example of TCA?
A. Paxil
B. Zoloft
C. Nardil
D. Pamelor

55. A client visits the physician’s office to seek treatment for depression, feeling of hopelessness, poor appetite,
insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these
symptoms began at least 2 years ago. Based on this report, the nurse suspects:
A. cyclothymic disorder
B. Major depression
C. Bipolar disorder
D. Dysthymic disorder

56. The nurse is planning activities for a client who has bipolar disorder, which aggressive social behaviour. Which
of the following activities would be most appropriate for this client?
A. Ping Pong
B. Linen Delivery
C. Chess
D. Basketball

mania. The symptom

s:
A. Outlandish behaviour and inappropriate dress
B. Grandiose delusion of being a royal descendant of King Arthur
C. Nonstop physical activity and poor nutritional intake
D. Constant incessant talking that includes sexual topic and teasing.
58. A nurse is conducting a group therapy session and during the session. A client with mania consistently talks and
dominates the group. The behaviour is disrupting the group interaction. The nurse would initially:
A. Ask the client to leave the group session.
B. Tell the client that she will not be allowed to attend any more group sessions.
C. Tell the client that she needs to allow other client in a group time to talk.
D. Ask another nurse to escort the client out of the group session.

59. A professional artist is admitted to the psychiatric unit for treatment of bipolar disorder. During the last 2
weeks, the client has created 154 paintings, slept only 2 to 3 hours every 2 days, and lost 18 lb. (8.2 kg). Based on
Maslow’s hierarchy of needs, what should the nurse provide this client with first?
A. The opportunity to explore family dynamics
B. Help with re-establishing a normal sleep pattern.
C. Experiences that build self-esteem.
D. Art materials and equipment.

60. The physician orders lithium carbonate (Lithonate) for a client who’s in the manic phase of bipolar disorder.
During lithium therapy, the nurse should watch for which adverse reactions?
A. Anxiety, restlessness, and sleep disturbance
B. Nausea, diarrhea, tremor, and lethargy
C. Constipation, lethargy, and ataxia
D. Weakness, tremor, and urine retention

Situation 10 – Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is:

61. The accurate information of the nurse the goal of desensitization is:
A. To help the clients relax and progressively work up a list of anxiety provoking situations through imagery
B. To provide corrective emotional experiences through a one-to-one intensive relationship
C. To help clients in a group therapy setting to take on specific roles and reenact in front of an audience, situations
in which interpersonal conflict is involved.
D. To help clients cope with their problems by learning behaviors that we are more functional and be
better equipped to face reality and make decisions.

62. It is essential in desensitization for the patient to:

A. Have a rapport with therapist
B. Use deep breathing or another relaxation technique
C. Assess one’s self for the need of anxiolytic drug
D. Work through unresolved unconsciousness conflicts

63. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences turned
vision. Physical signs of anxiety become more pronounced.
A. Severe anxiety
B. Panic
C. Mild anxiety
D. Moderate anxiety

64. Anti-anxiety medication should be used with extreme caution because long term use can lead to.
A. Parkinsonian like syndrome
B. Hypertensive crisis
C. Hepatic failure
D. Risk of addiction

65. The nursing management of anxiety related with post traumatic stress disorder includes all of the following
EXCEPT:
A. Encourage participation in recreation or sport activities
B. Reassurance client’s safety while touching client
C. Speak in calm soothing voice
D. Remain with the client while fear level is high

SITUATION 11: You are fortunate to be chosen as part of the research team in the hospital. A review of the following
IMPORTANT nursing concepts was made.

66. As a professional, a nurse can do research for varied reason except:

A. Professional advancement through research participation
B. To validate results of new nursing modalities
C. For financial gains
D. To improve nursing care
67. Each nurse participants was asked to identify a problem. After the identification of the research problem, which
of the following should be done?
A. Methodology
B. Review of related literature
C. Acknowledgement
D. Formulate hypothesis

68. Which of the following communicate the results of the research to the readers. They facilitate the description of
the data.
A. Hypothesis
B. Statistics
C. Research Problem
D. Tables and Graphs

69. In Quantitative date, which of the following is described as the distance in the scoring unites of the variable
from the highest to the lower?
A. Frequency
B. Mean
C. Median
D. Range

70. This expresses the variability of the data in reference to the mean. It provides as with a numerical estimate of
how far, on the average the separate observation are from the mean:
A. Mode
B. Standard deviation
C. Median
D. Frequency

Situation 12: Survey and Statistics are important part of research that is necessary to explain the characteristics of
the population.

71. According to the WHO statistics on the Homeless population around the world. Which of the following groups of
people in the world disproportionately represents the homeless population?
A. Hispanics
B. Asians
C. African Americans
D. Caucasians

72. All but one of the following is not a measure of Central Tendency?
A. Mode
B. Variance
C. Standard Deviation
D. Range

73. In the value: 87, 85, 88, 92, 90: What is the mean?
A. 88.2
B. 88.4
C. 87
D. 90

74. In the value: 80, 80, 80, 82, 82, 90, 90,100. What is the mode?
A. 80
B. 82
C. 90
D. 85.5.

75. In the value 80, 80, 10, 10, 25, 65, 100, 200: What is the median?
A. 71.25
B. 22.5
C. 10 and 25
D. 72.5

76. Draw Lots, Lottery, Table of random numbers or a sampling that ensures that each element of the population
has an equal and independent chance of being chosen is called:
A. Cluster
B. Simple
C. Stratified
D. Systematic

77. An investigator wants to determine some of the problems that are experienced by diabetic clients when using
an Insulin pump. The investigation went into a clinic where he personally knows several diabetic clients having
problem with insulin pump. The type of sampling done by the investigator is called:
A. Probability
B. Purposive
C. Snowball
D. Incidental

78. If the researcher implemented a new structured counselling program with a randomized group of subject and a
routine counselling program with another randomized group of subject, the research is utilizing which design?
A. Quasi experimental
B. Experimental
C. Comparative
D. Methodological

79. Which of the following is not rue about a Pure Experimental Research?
A. There is a control group
B. There is an experimental group
C. Selection of subjects in the control group is randomized
D. There is a careful selection of subjects in the experimental group

80. The researcher implemented a medication regimen using a new type of combination of drugs to manic patients
while another group of manic patient receives the routine drugs. The researcher however hand picked the
experimental group for they are the clients with multiple episodes of bipolar disorder. The researcher utilized which
research design?
A. Quasi-experimental
B. Pure experimental
C. Phenomenological
D. Longitudinal

Situation 13: As a nurse you are expected to participate in initiating or participating in the conduct of research
students to improve nursing practice. You to be updated on the latest trends and issues affected the profession and
the best practices arrived at by the profession.

81. You are interested to study the effects of medication and relaxation on the pain experienced by the cancer
patients. What type of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic

82. You would like to compare the support system of patient with chronic illness to those with acute illness. How will
you best state your problem?
A. A descriptive study to compare the support system of patients with chronic illness and those with acute illness in
terms of demographic data and knowledge
B. The effects of the types of support system of patients with chronic illness and those with acute illness
C. A comparative analysis of the support system of patients with chronic illness and those with acute
illness
D. A study to compare the support system of patients with chronic illness and those with acute illness.
E. What are the differences of the support system being received by patient with chronic illness and patients with
acute illness?

83. You would like to compare the support system of patients with chronic illness to those with acute illness.
Considering that the hypothesis was: “Clients with chronic illness have lesser support system than clients with
acute illness.” What type of research is this?
A. Descriptive
B. Experimental
C. Correlational, Non experimental
D. Quasi Experimental

84. In any research study where individual persons are involved, it is important that an informed consent of the
study is obtained. The following are essential information about the consent that you should disclose to the
prospective subject except:
A. Consent to incomplete
B. Description of benefits, risks and discomforts
C. Explaining of procedure
D. Assurance of anonymity and confidentiality

85. In the hypothesis: “The utilization of technology in teaching improves the retention and attention of the nursing
students.” Which is the dependent variable?
A. Utilization of technology
B. Improvement in the retention and attention
C. Nursing students
D. Teaching

Situation 14: You are actively practicing nurse who has just finished your graduate studies. You learned the value of
research and would like to utilize the knowledge and skills gained in the application of research to the nursing
service. The following questions apply to research.

86.Which type of research inquiry investigates the issue of human complexity (e.g. understanding the human
expertise)?
A. logical position
B. natural inquiry
C. positivism
D. quantitative research

87. Which of the following studies is based on quantitative research?

A. A study examining the bereavement express in spouse or clients with terminal cancer
B. A study exploring the factors influencing weight control behaviour
C. A study measuring the effects of sleep deprivation on patients healing
D. A study examining client’s feeling before, during and after bone marrow aspiration.

88. Which of the following studies is based on the qualitative research?

A. A study examining client’s reaction to stress after open heart surgery
B. A study measuring nutrition and weight loss/gain in clients with cancer
C. A study examining oxygen levels after endotracheal suctioning
D. A study measuring differences in blood pressure before, during and after procedure

89. An 85 year old client in a nursing home tells a nurse, “ I signed the papers of that research study because the
doctor was so insistent and I want him to continue taking care for me. “Which client right is being violated?
A. Right of self determination
B. Right to privacy and confidentiality
C. Right to self disclosure
D. Right not to be harmed

90. A supposition or system of ideas that is proposed to explain a given phenomenon best defines:
A. Paradigm
B. Concept
C. A theory
D. A conceptual framework

Situation 15: Mastery of research design determination is essential in passing the NLE.

91. Ana wants to know if the of time she will study for the board examination is proportional to her board rating.
During the June 2008 board examination. She studied for 6 months and gained 60%. On the next board exam, she
studied for 6 months again for a total of 1 year and gained 74%. On t third board exam, She studied for 6 months
for a total of 1 and a half year and gained 82%. The research she used is:
A. Comparative
B. Correlational
C. Experimental
D. Qualitative

92. Anton was always eating high fat diet. You want to determine if what will be the effect of high cholesterol food
to Anton in the next 10 years. You will use:
A. Comparative
B. Correlational
C. Historical
D. Longitudinal

93. Community A was selected randomly as well as community B, nurse Edna conducted teaching to Community A
and assess if community A will have a better status than community B. This is an example of:
A. Comparative
B. Correlational
C. Experimental
D. Qualitative

94. Ana researched on the development of a new way to measure intelligence by creating a 100 item questionnaire
that will assess the cognitive skills of an individual. The design best suited for this study is:
A. Historical
B. Methodological
C. Survey
D. Case study

95. Gen is conducting a research study on how mark, an AIDS client lives his life. A design suited for this is:
A. Historical
B. Case Study
C. Phenomenological
D. Ethnographic

96. Marco is to perform a study about how nurses perform surgical asepsis during World War II. A design for this
study is:
A. Historical
B. Case Study
C. Phenomenological
D. Ethnographic

97. Tonyo conducts sampling at barangay 412. He collected 100 random individuals and determine who is their
favourite comedian actor. 50% said Dolphy, 20% said Vic Sotto, while some answered Joey de Leon, Allan K, Michael
V. Tonyo conducted what type of researched study?
A. Methodological
B. Case Study
C. Non experimental
D. Survey

98. June visited a tribe located somewhere in China, it is called the Shin Jea tribe. She studied the way of life,
tradition and the societal structure of these people. Jane will best use which research design?
A. Historical
B. Case Study
C. Phenomenological
D. Ethnographic

99. Anjoe researched on TB. Its transmission, Causative agent and factors, treatment, sign and symptoms as well as
medication and all other in depth information about tuberculosis. This study is best suited for which research
design?
A. Historical
B. Case Study
C. Phenomenological
D. Ethnographic

100. Diana is to conduct a study about the relationship of The number of family members in the household and the
electricity bill. Which of the following is best research design suited for this study?
1. Descriptive
2. Exploratory
3. Explanatory
4. Correlational
5. Comparative
6. Experimental

A. 1, 4 B. 2, 5 C. 3,6 D. 1, 5 E. 2, 4

NP5 Nursing Board Exam November Answer Key 'Nursing

Care of Client with Physiological and Psychosocial
Alteration'
100 Nursing Board Exam test questions of November 2008 Nurse Licensure Examination (NLE)
Nursing Practice V – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology

PART 1 Board Exam test questions 1 - 50

Nov. ’08 NP 5

Situation 1: Understanding different models of care is a necessary part of the nurse patient relationship.

1. The focus of this therapy is to have a positive environmental manipulation, physical and social to effect a positive change.

A. Milieu

B. Psychotherapy

C. Behaviour

D. Group

2. The client asks the nurse about the Milieu therapy. The nurse responds knowing that the primary focus of milieu therapy can be

best described by which of the following?

A. A form of behaviour modification therapy

B. A cognitive approach of changing the behaviour

C. A living learning or working environment

D. A behavioural approach to changing behaviour

3. A nurse is caring to client with phobia who is being treated for the condition. The client is introduced to short periods of exposure

to the phobia object while in relaxed state. The nurse understands that this form of behaviour modification can be best described as:

A. Systematic desensitization

B. Aversion therapy

C. Self-control therapy

D. Operant conditioning

4. A client with major depression is considering cognitive therapy. The client say to the nurse, “how does this treatment works?” The

nurse responds by telling the client that:

A. “This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties”

B. “This type of treatment helps you examine how your past life has contributed to your problems.”

C. “This type of treatment helps you confront your fears by exposing you to the feared objects abruptly.”

D. “This type of treatment will help you relax and develop new coping skills.”

5. A client state, “I get down on myself when I make mistake.” Using Cognitive therapy approach, the nurse should:

A. Teach the client relaxation exercise to diminish stress

B. Provide the client with Mastery experience to boost self esteem

C. Explore the client’s past experiences that causes the illness

D. Help client modify the belief that anything less than perfect is horrible.

6. The most advantageous therapy for a preschool age child with a history of physical and sexual abuse would be:

A. Play

B. Psychoanalysis

C. Group

D. Family

7. An 18 year old client is admitted with the diagnosis of anorexia nervosa. A cognitive behavioural approach is used as part of her

treatment plan. The nurse understands that the purpose of this approach is to:

A. Help the client identify and examine dysfunctional thoughts and beliefs.

B. Emphasize social interaction with clients who withdraw

C. Provide a supportive environment and a therapeutic community

D. Examine intrapsychic conflicts and past events in life

8. The nurse is preparing to provide reminiscence activity for a group of clients. Which of the following clients will the nurse select for

this group?

A. A client who experiences profound depression with moderate cognitive impairment

B. A catatonic, immobile with moderate cognitive impairment

C. An undifferentiated schizophrenic client with moderate cognitive impairment

D. A client with mild depression who exhibits who demonstrates normal cognition

9. Which intervention would be typical of a nurse using cognitive-behavioral approach to a client experiencing stress disorders?

A. Use of unconditional positive regard

B. Classical conditioning

C. Analysis of free association

D. Examination of negative thought patterns

10. Which of the following therapies has been strongly advocated for the treatment of post traumatic stress disorders?

A. ECT
B. Group Therapy

C. Hypnotherapy

D. Psychoanalysis

11. The nurse knows that in group therapy, the maximum number of members to include is:

A. 4

B. 8

C. 10

D. 16

12. The nurse is providing information to a client with the use of disulfiram (antabuse) for the treatment of alcohol abuse. The nurse

understands that this form of therapy works on what principle?

A. Negative Reinforcement

B. Aversion Therapy

C. Operant Conditioning

D. Gestalt therapy

13. A biological or medical approach in treating psychiatric patient is:

A. Million therapy
B. Somatic therapy

C. Behavioral therapy

D. Psychotherapy

14. Which of these nursing actions belong to the secondary level of preventive intervention?

A. Providing mental health consultation to health care providers

B. Providing emergency psychiatric services

C. Being politically active in relation to mental health issues

D. Providing mental health education to members of the community

15. When the nurse identifies a client who has attempted to commit suicide the nurse should:

A. call a priest

B. Counsel the client

C. refer the client to psychiatrist

D. refer the matter to the police

Situation 2: Rose seeks psychiatric consultation because of intense fear of flying in an airplane which has greatly affected her

chances of success in her job.

16. The most common defense mechanism used by phobic client is:

A. Supression

B. Rationalization

C. Denial

D. Displacement

17. The goal of the therapy in phobia is:

A. Change her lifestyle

B. Ignore reaction producing situation

C. Change her reaction towards anxiety

D. Eliminate fear producing situation

18. The therapy most effective for clients with phobia is:

A. Hypnotherapy

B. Group therapy

C. Cognitive therapy

D. Behavior therapy
19. The fear and anxiety related to phobia is said to be abruptly decreased when the patient exposed to what is feared through:

A. Guided imagery

B. Systematic desensitization

C. Flooding

D. Hypotherapy

20. Based on the presence of symptom. The appropriate nursing diagnosis is:

A. Self esteem disturbance

B. Activity intolerance

C. Impaired adjustment

D. Ineffective individual coping

Situation 3: Mang Jose, 39 year old farmer, unmarried, had been confined in the National center for mental health for three years

with a diagnosis of schizophrenia.

21. The most common defense mechanism used by a paranoid client is:

A. Displacement

B. Suppression

C. Rationalization
D. Projection

22. When Mang Jose says to you: “The voices are telling me bad things again!” The best response is:

A. “Whose voices are those?”

B. “I doubt what the voices are telling you.”

C. “I do not hear the voice you say you hear.”

D. “Are you sure you hear these voices?”

23. A relevant nursing diagnosis for clients with auditory hallucination is:

A. Sensory perceptual alteration

B. Altered thought process

C. Impaired social interaction

D. Impaired verbal communications

24. During mealtime, Jose refused to eat telling that the food was poisoned. The nurse considers the following except:

A. Ignore his remark

B. Offer him food in his own container

C. Show him how irrational his thinking is

D. Respect his refusal to eat.

25. When communicating with Jose. The nurse considers the following except:

A. Be Warm and enthusiastic

B. Refrain from touching Jose

C. Do not argue regarding his hallucination and delusion

D. Use simple, clear language

Situation 4: Gringo seeks psychiatric counselling for his ritualistic bahavior of counting his money as many as 10 times before leaving

home.

26. An initial appropriate nursing diagnosis is:

A. Impaired social interaction

B. Ineffective individual coping

C. Impaired Adjustment

D. Anxiety Moderate

27. Obsessive compulsive disorder is BEST described by:

A. Uncontrollable impulse to perform an act or ritual repeatedly:

B. Persistent thoughts

C. Recurring unwanted and disturbing thoughts alternating with a behaviour.

D. Pathological persistence of unwilled thought, feeling or impulse

28. The defense mechanism used by persons with obsessive compulsive disorder is undoing and it is best described in one of the

following statements:

A. Unacceptable feeling or behaviour are kept out of awareness by developing the opposite behaviour or emotion.

B. Consciously unacceptable instinctual drives are diverted into personally and socially acceptable channels

C. Something unacceptable already done is symbolically acted in reverse.

D. Transfer of emotions associated with a particular person, object or situation to another less threatening person, object or situation.

29. TO be more effective, the nurse who cares for persons with obsessive compulsive disorder must possess one of the following

qualities:

A. Compassion

B. Consistency

C. Patience

D. Friendliness

30. Person with OCD usually manifest:

A. Fear

B. Apathy

C. Suspiciousness

D. Anxiety

Situation 3: The patient who is depressed will undergo electroconvulsive therapy.

31. Studies on biological depression support electroconvulsive therapy as a mode of treatment. The rationale is:

A. ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding

the development of psychotic condition

B. The treatment serves as a symbolic punishment for the client who feels guilty and worthless

C. ECT relieves depression psychologically by increasing the norepinephrine level

D. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses

to deal with this attack.

32. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for:

A. electroencephalogram

B. X-ray

C. general anesthesia

D. electrocardiogram

33. Which of the following is a possible side effect which you will discuss with the patient?

A. hemorrhage within the brain

B. robot-like body stiffness

C. encephalitis

D. confusion, disorientation and short term memory loss

34. Informed consent is necessary for the treatment for involuntary clients. When this cannot be obtained, permission may be taken

from the:
A. social worker

B. doctor

C. next of kin or guardian

D. chief nurse

35. After ECT, the nurse should do this action before giving the client fluids, food or medication:

A. assess the gag reflex

B. assess the sensorium

C. next of kin or guardian

D. check O2 Sat with a pulse oximeter

Situation 6: Mrs. Ethel Agustin 50 y/o, teacher is affected with myasthenia gravis

36. Looking at Mrs. Agustin, your assessment would include the ff except:
A. Nystagmus

B. Difficulty of hearing

C. Weakness of the levator palpebrae

D. Weakness of the ocular muscle

37. In an effort to combat complications which might occur relatives should be taught:

A. Checking cardiac rate

B. Taking blood pressure reading

C. Techniques of oxygen inhalation

D. Administration of oxygen inhalation

38. The drug of choice for her condition is:

A. Prostigmine
B. Morphine

C. Codeine

D. Prednisone

39. As her nurse, you have be cautious about administration of medication, if she is undermedicated this can cause:

A. Emotional crisis

B. Cholinergic crisis

C. Menopausal crisis

D. Myasthenia crisis

40. If you are extra careful and by chance you give over medication, this would lead to:

A. Cholinergic crisis

B. Menopausal crisis

C. Emotional crisis
D. Myasthenia crisis

Situation 7: Rosanna 20 y/0 unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and

refuses to use it unless she flushes it three times and wipes the seat same number of times with antiseptic solution.

41. The fear of using “contaminated” toilet seat can be attributed to Rosanna’s inability to:

A. Adjust to a strange environment

B. Express her anxiety

C. Develop the sense of trust in other person

D. Control unacceptable impulses or feelings

42. Assessment data upon admission help the nurse to identify this appropriate nursing diagnosis

A. Ineffective denial

B. Impaired adjustment
C. Ineffective individual coping

D. Impaired social interaction

43. An effective nursing intervention to help Rosana is:

A. Convincing her to use the toilet after the nurse has used it first.

B. Explaining to her that AIDS cannot be transmitted by using the toilet

C. Allowing her to flush and clear the toilet seat until she can manage her anxiety

D. Explaining to her how AIDS is transmitted.

44. The goal for treatment for Rosana must be directed toward helping her to:

A. Walk freely about her past experience

B. Develop trusting relationship with other

C. Gain insight that her behaviour is due to feeling of anxiety

D. Accept the environment unconditionally

45. Psychotherapy which is prescribed for Rosana is described as:

A. Establishing an environment adapted to an individual patient needs

B. Sustained interaction between the therapist and client to help her develop more functional behaviour

C. Using dramatic techniques to portray interpersonal conflicts

D. Biologic treatment for mental disorder

Situation 8: Dennis 40 y/o married man, an electrical engineer was admitted with the diagnosis of paranoid disorders. He has became

suspicious and distrustful 2 months before admission. Upon admission, he kept on saying, “my wife has been planning to kill me.”

46. A paranoid individual who ca not accept the guilt demonstrate one of the following defense mechanism:

A. Denial
B. Projection

C. Rationalization

D. Displacement

47. One morning, Dennis was seen tilting his head as if he was listening to someone. An appropriate nursing intervention would be:

A. Tell him to socialize with other patient to diverts his attention

B. Involve him in group activities

C. Address him by name to ask if he is hearing voices again

D. Request for an order of antipsychotic medicine

48. When he says, “these voices are telling me my wife is going to kill me.” A therapeutic communication of the nurse is which one of

the following:

A. “I do not hear the voices you say you hear.”

B. “Are you really sure you heard those voices?”

C. “I do not think you heard those voices?”

D. “Whose voices are those?”

49. The nurse confirms that Dennis is manifesting auditory hallucination. The appropriate nursing diagnosis she identifies is:

A. Sensory perceptual alteration

B. Self esteem disturbance

C. Ineffective individual coping

D. Defensive coping

50. Most appropriate nursing intervention for a client with suspicious behaviour is one of the following:

A. Talk to the client constantly to reinforce reality

B. Involve him in competitive activities

C. Use of Non Judgemental and Consistent approach

D. Project cheerfulness in interacting with the patient