3554 Final
ATI Ch 27 Grief #5 A nurse is caring for a client who lost his mother to cancer last month. The client states, I'd still have my mother if the doctor would have diagnosed her sooner. Which of the following responses should the nurse make? A. you sound angry. anger is a normal feeling associated with loss B. I think you would feel better if you talked about your feelings with a support group C. I understand just how you feel. I felt the same when my mother died D. Do other members of your family also feel this way
A
ATI Ch 33 Sexual Assault #3 A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. I will admin prophylactic treatment for sexually transmitted infection like chlamydia B. I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence C. I can expect manifestations of rape trauma syndrome to be similar to bipolar D. I should use narrative documentation when documenting subjective data
A
Ch 11 Child and Neurodevelopment DO #2 The nurse is preparing to assess a child who primarily speaks Spanish, but is fluent in English. Which is the appropriate method for gathering information? A. begin the assessment in english B. utilize a Spanish dictionary to ask questions of the child C. ask the child if he understands english D. obtain a interpreter who is fluent in spanish
A
Ch 21 Impulse Control #2 You are caring for Gabby, a 12 year old patient diagnosed with oppositional defiant disorder. Gabby's mother asks you what type of medication is usually prescribed for this diagnosis. Your answer is based on the knowledge that: A. treatment of this disorder doesn't usually involve any specific medication but focuses on adaptive coping mechanisms B. interventions for this disorder include treatment with mood stabilizers or off label uses of other classifications of medications C. a care plan may include medication, but the patient will outgrow the behavioral problems without any specific treatment D. psychiatric medications have not been proven to work in child and adolescents
A
Ch 26 Crisis and Disaster #1 Which statement about crisis theory will provide a basis for nursing interventions? A. a crisis is an acute, time limited phenomenon experienced as an overwhelming emotional reaction to a problem perceived as unsolvable B. A person in crisis has always had adjustment problems and has coped inadequately in his or her usual life situations C. crisis is precipitated by an event that enhances a person's self concept and self esteem D. nursing interventions in crisis situations rarely have the effect of ameliorating the crisis
A
Ch 26 Crisis and Disaster #3 When responding to the patient in question 2 (lilly single mother in fire), the intervention that takes priority is to: A. reduce anxiety B. arrange shelter C. contact out of area family D. hospitalize and place the patient on suicide precautions
A
Ch 26 Crisis and Disaster #4 Which belief would be least helpful for a nurse working in crisis intervention? A. a person in crisis is incapable of making decisions B. the crisis counseling relationship is one between partners C. crisis counseling helps the patient refocus to gain new perspectives on the situation D. anxiety reduction techniques are used so the patient's inner resources can be accessed
A
Ch 26 Crisis and Disaster #5 The highest priority goal of crisis intervention is: A. patient safety B. anxiety reduction C. identification of situational supports D. teaching specific coping skills that are lacking
A
Ch 29 Sexual Assault #4 you are working at a telephone hotline center when Abby, a rape victim calls. Abby states she is afraid to go to the hospital. What is your best response? A. i'm here to listen, and we can talk about your feelings B. you don't need to go to the hospital if you don't want to C. If you don't go tot he hospital, we can't collect evidence to help convict your rapist D. why are you afriad to seek medical attention
A
Ch 32 Forensics #3 The psychiatric forensic nurse (PFN) has been asked to evaluate an incarcerated patient who has mental health problems for a competency hearing.. As the patient is being considered for sentencing, what is the PFN's role? A. assess the patient for level of competency B. determine whether the patient is guilty or innocent C. assist in determine the length of the sentence d. complete a formal report to the court e. become an advocate for the incarcerated patient
A
Ch 34 Family Interventions #5 You are evaluating the family therapy experience. Which behavior would indicate that further family therapy is needed? A. wife talks to husband through the children B. Son's grades have risen from a D to a C average C. Daughter's headaches have subsided D. mother has stopped using illicit substances
A
Ch 29 Flashbacks, frightening thoughts, recurrent memories or dreams are associated with which category of symptoms in post-traumatic stress disorder? A. Re-experiencing B. Hyperarousal C. Avoidance
A Re-experiencing includes flashbacks, frightening thoughts, recurrent memories or dreams, and physical reactions to situations that remind a victim of the event.
ATI Ch 32 #5 A nurse is caring for an adult client who has injuries resulting form intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. advise the client about the location of women's shelters B. encourage the client to participate in a support group for survivors of abuse C. implement case management to coordinate community and social services D. educate the client about the use of stress management techniques
A greatest risk is injury from abuse so assist in developing a safety plan first
ATI Ch 27 Grief #4 A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (select all) A. i amy experience feelings of resentment B. I will probably withdraw from others C. I can expect to experience changes in sleep D. It is possible that I will experience suicidal thoughts E. it is expected that I will have a loss of self esteem
A, B, C
ATI Ch 28 Children #3 A nurse is obtaining a health history from the parents of a 12 year old client who has conduct disorder. Which of the following findings should the nurse expect? (select all) a. bullying of others B. threats of suicide C. law breaking behaviors D. narcissistic behavior E. flat affect
A, B, C
ATI Ch 27 Grief #3 A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability (select all) A. interpersonal relationships B. culture C. birth order D. religious beliefs E. prior experience with loss
A, B, D, E
Ch 28 Violence #4 Perpetrators of domestic violence tend to: (select all) A. have relatively poor social skills and have grown up with poor role models B. believe they, if male, should be dominant and in charge of relationships C force their mates to work and expect them to handle the financial decisions D. be controlling and willing to use force to maintain their power in relationships E. prevent their mates from having relationships and activities outside of the family
A, B, D, E
ATI Ch 33 Sexual Assault #1 A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should ID which of the following characteristics as expected for this type of reaction? (select all) A. sudden development of phobias B. development of substance use disorder C. increased level of anxiety during interview D. reactivation of prior physical disorder E. unwillingness to discuss sexual assault
A, C, E
Ch 29 Sexual Assault #5 Josefina was raped 6 months ago. Which symptoms should you anticipate for long term successful outcomes? Select all A. evidence of comfort in relationships B. numbness, shock, and disbelief C. recognition of the right to be protected from abuse D. fear of sexual encounters E. dreams of violent content F. anxiety being placed by calmness G. absence of phobia of being alone
A, C, F, G
ATI Ch 28 Children #5 A nurse is assessing a 4 year old child for indications for autism spectrum disorder. For which of the following manifestations should the nurse assess? A. impulsive behavior B. repetitive counting C. destructiveness D. somatic behavior
B
ATI Ch 33 Sexual Assault #5 A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching A. rape is a crime of passion B. acquaintance rape often involves alcohol C. young adults are the typical victims of sexual assault D. the majority of rapists are unknown to the victims
B
Ch 17 Somatic Disorders #2 A suitable outcome criterion for the nursing diagnosis Ineffective Coping r/t dependence on pain relievers to treat chronic pain of psychological origin is: A. patient will participate in self care with optimal participation B. patient will learn and practice effective coping skills C. patient will demonstrate improved self esteem as evidenced by focusing less on weaknesses D. patient will replace demanding, manipulative behaviors with more socially acceptable behavior
B
Ch 17 Somatic Disorders #4 Lucas is a nurse on the medical floor caring for Kelly, a 48 year old patient with newly diagnosed T2D. He realizes that depression is a complicating factor in the patient's adjustment to her new diagnosis. What problem has the most potential to arise? A. development of agoraphobia B. treatment non-adherence C. frequent hypoglycemic reactions D. sleeping rather than checking blood sugar
B
Ch 21 Impulse Control #1 Joshua, a 17 year old outpatient, has been diagnosed with intermittent explosive disorder. As you care for Joshua, you anticipate that the psychiatric care provider may prescribe which of the following? A. a benzodiazepine B. an anticonvulsant C. a psychostimulant D. an anticholinesterase inhibitor
B
Ch 26 Crisis and Disaster #2 Lilly, a single mother of four, comes to the crisis center 24 hours after an apartment fire in which all the family's household goods and clothing were lost. Lilly has no other family in the area. Her efforts to mobilize assistance have been disorganized, and she is still without shelter. She is distraught and confused. You assess the situation as: A. a maturational crisis B. a situational crisis C. an adventitious crisis D. existential crisis
B
Ch 28 Violence #1 An appropriate expected outcome in family therapy regarding the perpetrator of abuse would be: A. decrease in family interaction so there are fewer opportunities for abuse to occur B. perpetrator will recognize destructive patterns of behavior and learn alternate responses C. perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy D. a triad of treatment modalities, including medication, counseling, and role playing opportunities
B
Ch 32 Forensics #5 You are caring for Naomi, who has been arrested and is found to be at risk for alcohol and drug dependence/abuse. Which approach is thought to be most useful in treatment Naomi? A. recommend that the patient receive treatment when released from jail B. provide immediate drug/alcohol treatment plan C. immediately withdraw all medications D. isolate the patient until withdrawal from drugs is complete
B
Ch 34 Family Interventions #1 Just before you escort the Juarez family in for a meeting, their 17 year old son confides to you that he is gay. He says he has not told any other adult, including his parents. What is your best response to him? A. your parents have a right to know about this B. how do you think your parents would react if you told them? C. that's your decision, but you need to be careful about risky sexual behavior D. lots of famous people are gay. you don't need to worry
B
Ch 34 Family Interventions #4 Which of the following family members should you refer to individual therapy rather than family therapy? A a mother who has anxiety controlled by medication B. a father who is questioning his sexuality C. a son who is verbally abusive toward his parents D. a daughter who has been treated for alcohol abuse
B
Ch 28 Child abuse perpetrators are most often A. extended family members. B. child care workers. C. the child's parents. D. strangers.
C 80% of perpetrators are victim's parents
ATI Ch 29 Crisis Management #1 A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturation crisis? A. rape B. marriage C. severe physical illness D. job loss
B marriage is a naturally occurring event in the life span so its maturational
ATI Ch 32 Violence #4 A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. refusing to pay bills for a dependent, even when funds are available, is neglect B. intentionally causing an older adult to fall is an example of physical violence C. striking an intimate partner is an example of sexual violence d. failure to provide a stimulation environment for normal development is emotional abuse
B physical violence when pain or harm is directed towards individual
ATI Ch 27 Grief #2 A charge nurse is reviewing Kubler-Ross: 5 stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (select all) A. disequilibrium B. denial C. bargaining D. anger E. depression
B, C, D, E
ATI Ch 32 Violence #2 A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (select all) A. sunken fontanels B. respiratory distress C. retinal hemorrhage D. altered level of consciousness E. increase in head circumference
B, C, D, E bulging fontanel is expected in this syndrome
Ch 28 Violence #3 Nathan, a nursing student, is assigned to care for Shawna, who is recovering form injuries received during an episode of domestic violence, the third such assault for which she has received treatment. Nathan left home at age 17 to escape an abusive father. Which statement about Nathan's situation is accurate? Select all A. he may be prone to blame the patient for her injuries and abuse B. his personal experiences give him special insight into the needs for this patient C. His experiences are likely to make him more empathetic towards victims D. Caring for victims of abuse will help him cope with his own abuse experiences E. He may experience overwhelming emotions as a result of caring for abuse victims F. he would likely benefit from clinical supervision related to caring for abuse victims
B, C, E, F
ATI Ch 28 Children #2 A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following manifestations should the nurse expect? (select all) A. fear of being alone B. substance use C. weight gain D. irritability E. aggressiveness
B, D, E
Ch 11 Child and Neurodevelopment DO #5 The nurse is caring for a patient with attention deficit hyperactivity disorder. The child has been prescribed methylphenidate (Ritalin). Which of the following symptoms are SE the nurse will monitor for? (select all) A. hypotension B. decreased appetite C. sedation D. insomnia E. headache F. seizure
B, D, E
ATI Ch 32 Violence #3 A nurse working in an ED is assessing a preschool age child who reports abdominal pain. When conducting a head to toe assessment, which of the following findings should alert the nurse to possible abuse? (select all) A. abrasions on knees B. round burn marks on forearms C. mismatched clothing D. abdominal rebound tenderness E. areas of ecchymosis on torso
B, E
ATI Ch 29 Crisis Management #2 A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (select all) A. Lithium carbonate B. paroxetine C. risperidone D. haloperidol E. lorazepam
B, E SSRI antidepressant to decrease anxiety and depression Benzo to decrease anxiety of client experiencing a crisis
ATI Ch 33 Sexual Assault #4 A nurse is caring for a client who was recently raped. The client states "I never should have been out on the street alone at night". Which of the following responses should the nurse make? A. your actions had nothing to do with what happened B. You should focus on recovery rather than blaming yourself for what happened C. you believe this wouldn't have happened if you hadn't been out alone? D. why do you feel you should not have been alone one the street at night?
C
Ch 11 Child and Neurodevelopment DOs #1 A nurse is developing a care plan for a teen patient with attention deficit hyperactivity disorder who is at high risk for self harm due to poor judgement, high risk taking behaviors, and impulsivity. Which of the following is the priority nursing intervention? A. schedule a regular nurse patient session daily, and encourage her to explore stressors that may worsen her depressed mood B. develop a no self harm contract with the patient and encourage her to engage in all unit activities C. Assign a staff member one to one close observation until the treatment team determines she is no longer a risk to self D. the patient is to wear hospital issue clothing and sit/sleep within view of the staff until physician determines she is no longer a risk for self harm
C
Ch 17 Somatic Disorders #3 You are caring for Yolanda, a 67 year old patient who has been receiving hemodialysis for 3 months. Yolanda reports that she feels angry whenever it is time for her dialysis treatment. You attribute this to: A. organic changes in Yolanda's brain B. a flaw in Yolanda's personality C. a normal response to grief and loss D. denial of the reality of a poor prognosis
C
Ch 21 Impulsive Disorders #3 Blake is a 15 year old patient admitted for emergency observation after stealing a car and being pulled over by the police for reckless driving. He also has a history of pyromania. Which of the following is the priority assessment? A. Illegal behaviors in the past 6 months B. assessment of childhood development and family interactions C. suicide risk D. feelings of remorse
C
Ch 28 A 12-year-old child is admitted to the ED with a broken wrist, swollen eye, and fractured jaw. The child agrees to tell what actually happened if the nurse promises not to tell anyone. What would be the most appropriate nursing action? A. Agree to keep the child's secret to build trust. B. Ask the child's parents to explain what happened. C. Report the suspected abuse to child care services. D. Have the child talk to another victim of child abuse
C
Ch 28 Violence #5 You are assessing Lindy, a 25 year old woman who came to the ED with a broken arm. She sates she slipped on the ice on the steps outside her home. She has numerous other bruises in different stages of healing. Her boyfriend, with whom she lives, accompanied her to the ED and aggressively responds to questions posed to the patient, while the patient remains silent. What is your best response to the boyfriend? A. "it sounds as if you care a lot about LIndy. She is lucky to have such support" B. "by answer the questions for her, it sounds as if you don't want her to answer. What are you afraid of?" C "I now need to examine Lindy in private Please wait outside the room. I will come et you when we are finished: D. "I am calling security to have you escorted out because you are being obnoxious"
C
Ch 29 Sexual Assault #1 Tara, a 19 year old freshman college student, arrives for a follow up appointment at the mental health clinic where you work. She had previously been seen in the clinic for crisis intervention three weeks ago after being raped. Tara states, "my mom says I was asking for trouble because of the way I dressed at the party. She says when girls dress so sexy men can't hep themselves". Your response is guided by the knowledge that... A. stats show that women who dress provocatively are more likely to be raped B. the party setting is more a factor in rape occurrences than what the victim is wearing C. Rape is an act of violence, aggression, and power, not an expression of sexual needs D. Tara is exhibiting symptoms of an acute phase of rape trauma syndrome and will need further counseling sessions
C
Ch 29 Sexual Assault #2 You are working in the ED caring for a 21 year old Larissa, who has just been raped. Which is your best initial nursing response? A. "we need to examine you for injuries and collect evidence for the police: B. "may I get your consent to test you for pregnancy and HIV" C. You are safe here D. I will get you the number for the crisis intervention specialist
C
Ch 32 Forensic #1 Which role does the correctional nurse nOT fulfill within the corrections setting? A nursing assessment B. maintain proper safety procedures C. psychotherapist D. document patient progress
C
Ch 32 Forensics #2 Which statement regarding forensic nursing is accurate? A. forensic nurses must all be prepared at doctoral level B. forensic nurses focus on sexual assault exam as this fits within the scope of practice C. forensic psychiatric nurse examiners are prepared to conduct court ordered evaluations regarding sanity or competency D. forensic psychiatric mental health nurses are not permitted to act as hostage negotiators
C
Ch 34 Family Interventions #3 While you are working with a family whose son was admitted due to a psychotic break, you observe the mother say to her son, "What, no hug for your mom?" As the son embraces his mother, she stiffens, which results in the young man backing away. She responses "you only care about yourself." Which behavior is this mother engaging in? A. triangulation B. scapegoating C. double blinding D. differentiation
C
ATI Ch 28 Children #1 a nurse is assisting the parents of a school aged child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (select all) A. allow the child to choose consequences for negative behavior B. use role playing to act out unacceptable behavior C. develop a reward system for acceptable behavior D. encourage the child to participate in school sports E. be consistent when addressing unacceptable behavior
C, D, E
Ch 21 Impulsive Disorders #4 _____ disorder is one of the most frequently diagnosed disorders in children and adolescents and is a problem in the adult population as well, with adults experiencing the same type of symptoms. It is characterized by disregard of the rights of others and disdain for societal rules.
Conduct
ATI Ch 28 Children #4 A nurse in a pediatric clinic is caring for a preschool age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching? A. behaviors associated with ADHD are present prior to age 3 B. this disorder is characterized by argumentativeness C. below average intellectual functioning is assoc. with ADHD D. because of this disorder, your child is at an increased risk for injury
D
Ch 11 Child and Neurodevelopment DO #4 A 7 year old male without any other diagnosed problem engages in jaw clenching and rocking back and forth. Which condition should the nurse anticipate? A. attention deficit hyperactivity disorder B. Tourette's disorder C. Stereotypic movement disorder D. autism spectrum disorder
D
Ch 17 Somatic Disorders #1 The information that is least relevant when assessing a patient with a suspected somatization disorder is: A. understanding coping mechanisms B. results from diagnostic workups C. limitations in activities of daily living D. potential for violence
D
Ch 17 Somatic Disorders #5 You are caring for Aaron, a 38 year old patient diagnosed with somatic symptom disorder. When interacting with you, Aaron continues to focus on his severe headaches. In planning care for Aaron, which of the following interventions would be appropriate? A. Call for a family meeting with Aaron in attendance to confront Aaron regarding his diagnosis B. Educate Aaron on alternative therapies to deal with pain C. Improve reality testing by telling Aaron that you do not believe that the headaches are real D. Shift focus from Aaron's somatic concerns to feelings and effective coping skills
D
Ch 21 Impulsive Disorders #5 When working on an in patient adolescent mental health unit, staff may be able to maintain safety and a calm environment when they interact with patients using: A high expressed emotion--'you must stop that immediately'--using a stern tone B. strict rule adherence--'there are no stacks after 10. no exceptions'--using an authoritarian tone C. suppressed emotion--'hey let's just talk about something else that doesn't upset you'--using a light friendly tone D. low expressed emotion--'please go to your room for quiet time now'--using a neutral calm tone
D
Ch 28 Violence #2 You are discharging Vanessa, a 30 year old victim of domestic violence, from the ED. she has sustained bruises and abrasions, but no serious trauma. She is fearful that Children's Services will take custody of her daughter, Her daughter has not been harmed and is safe with Vanessa's mother. Which intervention on your part is indicated? A. report the assault to the police, because reporting of domestic violence is mandatory B probe Vanessa for info to use as evidence in prosecuting the perpetrator C. advise Vanessa to leave her abuse partner and move in with her mother D. assist Vanessa to develop a safety plan for rapid escape should abuse happen again
D
Ch 29 Sexual Assault #3 Mindy is the nurse caring for Caitlin, who was raped the night before. Caitlin is considering the morning after pill to prevent a possible pregnancy that may have resulted from the rape. Caitlin is concerned and states that she does not believe in abortion. Which of the following is the most appropriate action Mindy could take in this situation? A examine her own feelings about abortion before discussing this with Caitlin B. Encourage Caitlin to take more time to consider her options C. Provide Caitlin with the number to Planned Parenthood D. Provide Caitlin with medication education
D
Ch 32 Forensics #4 In order to determine the patient's legal sanity or competency the psychiatric forensic nurse must assess all of the following except A. the patient's ability to distinguish right from wrong regarding the act B. the patient's capacity to understand the nature of the act committed C. the evidence with respect to the defendant's mental state at the time of the act D. the patient's social network
D
ATI Ch 32 Violence #1 A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of the teaching? A. children older than 3 are at greater risk of abuse B. substance use disorder does not increase risk for violence C. entering an intimate relationship increases risk for violence d. pregnancy increases risk for violence toward intimate partner
D pregnancy tends to increase likelihood of violence
ATI Ch 33 Sexual Assault #2 A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape trauma syndrome? (select all) A. genitourinary soreness B. difficulties with low self esteem C. sleep disturbances D. emotional outbursts E. difficulty making decisions
D, E
Ch 34 Family Interventions #2 When performing an intake assessment on a family who has referred for family counseling, you wish to map the family's structure and information that reflect both the family's history and current functioning. This assessment tool is called a ______
Genogram
Ch 11 Child and Neurodevelopment DO #3 The nurse educator is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (4) restrictive A. allow the patient to sit in the sensory room B. place the patient in physical restraints C. place the patient in a locked seclusion room D. offer a PRN med by mouth
LEAST 1. A. allow the patient to sit in the sensory room 2.D offer a PRN med by mouth 3.C place the patient in a locked seclusion room 4.B place the patient in physical restraints MOST
Ch 28 Should nurses be legally mandated to report intimate partner abuse? Yes No Not sure
Reporting requirements regarding intimate partner abuse vary from state to state. Nurses are legally mandated to report suspected or actual cases of child and vulnerable adult abuse in all states.
ATI Ch 27 Grief #1 A nurse is caring for a client following the loss of her partner due to terminal illness. ID the sequence of Engel's five stages of grief that the nurse should expect the client to experience (select the stages of grief in order of occurence) A. developing awareness B. restitution c. shock and disbelief D. recovery E. resolution of the loss
Step 1: C shock and disbelief--experiences sense of numbness and denial over loss Step 2: A developing awareness--aware of reality of loss resulting in intense feelings of grief (within hours of loss) Step 3: B restitution: carries out cultural/religious rituals, such as funeral, following the loss Step 4: E resolution of the loss: preoccupied with loss; preoccupation gradually decreases over about a 12 month period Step 5: D recovery--client moves past the preoccupation with loss and forward with life