408 Exam 3 NCLEX Ch 7, 14, 36, 40

1. Which of the following represents a nursing intervention at the primary level of prevention? a. Teaching a class in parent effectiveness training b. Leading a group of adolescents in drug rehabilitation c. Referring a married couple for sex therapy d. Leading a support group for battered women

ANS: A

3. Which of the following represents a nursing intervention at the tertiary level of prevention? a. Serving as case manager for a mentally ill homeless client b. Leading a support group for newly retired men c. Teaching prepared childbirth classes d. Caring for a depressed widow in the hospital

ANS: A

9. The physician orders trazadone (Desyrel), 150 mg to be taken at bedtime, for Mrs. W., a 78-year-old widow with depression. Which of the following statements about this medication would be appropriate for the home health nurse to make in teaching Mrs. W. about trazadone? a. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down." b. "You must not eat chocolate while you are taking this medicine." c. "We will need to draw a sample of blood to send to the lab every month while you are on this medication." d. "If you don't feel better right away with this medicine, the doctor can order a different kind for you."

ANS: A

16. According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate? A. The nurse functions as a nurturing parent in order to build a trusting relationship. B. The nurse plays cards with a small group of clients. C. The nurse discusses childhood events that may affect personality development. D. The nurse provides a safe social environment.

ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate.

2. Two clients are roommates on an inpatient psychiatric unit. At breakfast, client A, who had been missing her gold locket, notices client B wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client A? A. Client A ignores the situation. B. Client A discusses the situation with her nurse and develops a plan of action. C. Client A immediately approaches client B and pulls the necklace off her neck. D. Client A offers to wash client Bs clothes and accidentally spills bleach in the water.

ANS: A By ignoring the situation, client A avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior.

10. Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurses action is promoting which assertive technique? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process

ANS: A Defusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues.

6. During an assertiveness training group, a nurse suggests using I statements. The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. When I statements are used, opinions are communicated without blaming others. B. When I statements are used, anger is displaced by using indirect means. C. When I statements are used, responsibility for ones behavior is attributed to another. D. When I statements are used, eye contact is promoted.

ANS: A I statements clearly state ones feelings and needs without blaming or demeaning others.

21. Which of the following are behavioral components of assertive communication? A. Listening B. You statements C. Closed posture D. Continuous direct eye contact

ANS: A One part of assertiveness communication and behavior is to listen and take time to understand what is being said before giving a response.

1. What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the clients length of stay D. To establish personal goals for the interaction

ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding ones own attitudes, values, and beliefs is called self-awareness.

5. Which client response should a nurse expect during the working phase of the nurseclient relationship? A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors.

ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurseclient relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

9. A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy? A. You are feeling very depressed. I felt the same way when I decided to leave my husband. B. I can understand you are feeling depressed. It was a difficult decision. Ill sit with you. C. You seem depressed. It was a difficult decision to make. Would you like to talk about it? D. I know this is a difficult time for you. Would you like a prn medication for anxiety?

ANS: A The nurses statement, You are feeling very depressed. I felt the same when I decided to leave my husband, is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the clients distress.

15. One nurse confronts another and says, You are always so talkative in the meetings. I dont know why you cant stay quiet sometimes. Which reply by the other nurse reflects the technique of clouding/fogging? A. Youre right. I do speak up a lot. B. Sounds to me like youre agitated and we need to talk. What are you truly angry about? C. Are you offended that I speak up, or because my thoughts are in opposition to yours? D. I have the right to express my opinion.

ANS: A This response reflects the use of clouding/fogging. When clouding/fogging is used it concurs with the critics argument without becoming defensive and without agreeing to change.

19. Which client statement may indicate a transference reaction? A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life. B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor. C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself. D. My mother is the source of my problems. She has always told me what to do and what to say.

ANS: A Transference occurs when a client unconsciously displaces or transfers to the nurse feelings formed toward a person from the past.

A nurse working for a large corporation is teaching relaxation therapy to employees. Which relaxation technique should the nurse initially teach? A. Deep-breathing exercises B. Mental imagery C. Biofeedback D. Meditation

ANS: A Deep breathing is a simple skill and is basic to other relaxation techniques and therefore should be taught first.

Which action should a nurse take prior to educating clients about relaxation techniques? A. Assisting the client in identifying triggers or sources of stress B. Performing a physical examination to qualify the client as a candidate for this therapy C. Obtaining an order from the physician D. Educating the client's family so they can be active participants in the therapy

ANS: A Initially helping clients to identify triggers and sources of stress will enable the client to anticipate the need for implementing relaxation techniques at appropriate times.

A client diagnosed with major depressive disorder refuses to get out of bed. Which nursing statement appropriately educates the client about the benefits of physical activity? A. "Depression is caused by the lack of certain brain chemicals that can increase with exercise." B. "Physical activity is good for everyone regardless of their diagnosis." C. "Low-intensity exercise is more beneficial than high-impact exercise." D. "When you are physically active, it helps to lower your beta endorphins."

ANS: A Physical activity can stimulate the secretion of norepinephrine and serotonin. Depression has been linked to low levels of these neurotransmitters.

6. Providing nursing education on drug abuse to a high school class is an example of which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Primary intervention

ANS: A Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary prevention services are aimed at reducing the incidence of mental health disorders within the population. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance

After suffering a myocardial infarction, a 37-year-old executive demands premature discharge from the hospital. He tells the nurse, "Just give me my prescriptions and let me get back to work." Which is the most appropriate nursing reply? A. "To ensure improved health, we need to discuss diet, medication, exercise, and lifestyle changes before you are discharged." B. "You will not be allowed to leave the hospital without getting your physician's approval for early discharge." C. "We will discharge you quickly so that the stress you are experiencing will not cause more serious heart damage." D. "Prior to discharge, we will need to discuss job stress, your finances, and the possibility of an early retirement."

ANS: A The client's statements reflect a great deal of stress that can contribute to further cardiovascular disease. Helping him to look at a variety of measures to improve his health would be most beneficial.

4. A client on the inpatient unit tells a student nurse, My life has no purpose. I cant think about living another day, but please dont tell anyone about the way I feel. I know you are obligated to protect my confidentiality. Which is the most appropriate reply by the student nurse? A. The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care. B. Lets discuss steps that will resolve negative lifestyle choices that may increase your suicidal risk. C. You seem to be preoccupied with self. You should concentrate on hope for the future. D. This information is secure with me because of client confidentiality.

ANS: A The most appropriate response by the student nurse is to explain that sharing the information with the treatment team is critical to the clients care. The nurses priority is to ensure client safety and to inform others of the clients suicidal ideation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

23. A nurse is caring for four clients. Which of the following clients should the nurse identify as likely to experience difficulty in being assertive? Select all that apply. A. A 20-year-old woman who is completing college homework assignments for several peers. B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder

ANS: A, B, C The woman who is taking on the work of others in addition to her own may be having difficulty assertively saying no; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy with a conduct disorder is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive.

10. Which of the following issues have been identified as contributing to the rise in the population of those who are homeless? (Select all that apply.) a. Poverty b. Lack of affordable health care c. Substance abuse d. Severe and persistent mental illness e. Growth in the number of family members living together

ANS: A, B, C, D

A nurse is teaching principles of mental imagery to a group. On which relaxing environments should the nurse appropriately recommend client focus? (Select all that apply.) A. Visualizing the seashore B. Visualizing a snowy cabin C. Driving home from the beach on Sunday evening D. Floating through the air on a cloud E. Lying at home in front of the fireplace

ANS: A, B, D, E Any environment that the client finds relaxing is appropriate. It is unlikely that a client would consider driving home from the beach on Sunday evening to be a relaxing environment.

2. Which of the following represents a nursing intervention at the secondary level of prevention? a. Teaching a class about menopause to middle-aged women b. Providing support in the emergency room to a rape victim c. Leading a support group for women in transition d. Making monthly visits to the home of a client with schizophrenia to ensure medication compliance

ANS: B

6. Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W., a 78-year-old widow who lives alone. Mrs. W.'s primary care physician has diagnosed her as depressed. Which of the following criteria would qualify Mrs. W. for home health visits? a. Mrs. W. never learned to drive and has to depend on others for her transportation. b. Mrs. W. is physically too weak to travel without risk of injury. c. Mrs. W. refuses to seek assistance as suggested by her physician, "because I don't have a psychiatric problem." d. Mrs. W. says she would rather have home visits than go to the physician's office.

ANS: B

1. During a psychoeducational group on assertiveness training, a client asks, Why do we need to learn about this stuff? Which is the most appropriate nursing reply? A. Because your doctor requires you to attend this group. B. Being assertive is the ability to stand up for yourself while respecting the rights of others. C. Assertiveness training teaches you how to ask for what you want, when you want it. D. Assertive people place the needs and rights of others before their own.

ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others.

18. What is the main goal of the working phase of the nurseclient therapeutic relationship? A. Role modeling to improve interaction with others B. Resolution of the clients problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment

ANS: B The goal of the working phase of the nurseclient therapeutic relationship is to resolve client problems by promoting behavioral change.

2. A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview. When the nurse postpones the admission interview, verbally assures safety, and provides a warm meal, he or she is promoting which of the following? A. Sympathy B. Trust C. Veracity D. Manipulation

ANS: B The nurse is promoting trust by postponing the admission interview, assuring safety, and providing a warm meal. Trust implies a feeling of confidence that a person is reliable and sincere and has integrity and veracity. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client.

11. If an individual is two-faced, which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? A. Respect B. Genuineness C. Sympathy D. Rapport

ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individuals ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship.

13. A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, Do you want to be my girlfriend? Which nursing response is most appropriate? A. You are upset now. It would be best if you go to your room until you feel better. B. Remember, we have a professional relationship. Are you feeling uncomfortable? C. We have discussed this before. I am not allowed to date clients. D. I think you should discuss your fantasies with your therapist.

ANS: B The nurse should promote the clients insight and perception of reality by confirming appropriate roles in the nurseclient relationship and identifying what is troubling the client in this situation.

20. Which nursing action demonstrates the role of the teacher in a therapeutic milieu? A. The nurse implements a self-affirmation exercise during a one-to-one client interaction. B. The nurse holds a group meeting to present common side effects of psychiatric medications. C. The nurse introduces the concept of fair play while playing cards with a group of clients. D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit.

ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the clients health.

7. Which phase of the nurseclient relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals? A. Preinteraction B. Orientation C. Working D. Termination

ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination.

4. What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship? A. Acknowledge the clients actions and generate alternative behaviors. B. Establish rapport and develop treatment goals. C. Attempt to find alternative placement. D. Explore how thoughts and feelings about this client may adversely impact care.

ANS: B The priority nursing action during the orientation phase of the nurseclient relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurseclient relationship.

4. A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, When I have to wait for more than an hour to be seen, I feel like my time is not important. The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passiveaggressive behavior D. Passive behavior

ANS: B This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation.

11. An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passiveaggressive statement by the emergency department nurse? A. Get someone else to work 3 to 11! Ive been working 10 days straight, and I need a break! B. Okay. Ill do it, then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me. D. Yes, Ill do it. Anything to keep peace with the hospital administration is a good thing.

ANS: B This response is passiveaggressive. The staff nurses anger is expressed indirectly.

16. A teenager gets a C in algebra. The mother angrily states, All you ever do is listen to music and text your friends. The teenager replies, What is it that youre really upset about, mom? Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for ones own statements

ANS: B This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction.

A client who has been referred for stress management asks the nurse, "Which one of these relaxation techniques requires reimbursement from my health insurance?" Which is the appropriate nursing reply? A. "Meditation requires reimbursement from health insurance." B. "Biofeedback requires reimbursement from health insurance." C. "Physical exercise requires reimbursement from health insurance." D. "Deep breathing requires reimbursement from health insurance."

ANS: B Biofeedback is costly and would require reimbursement from health insurance. It requires the use of a machine that gives immediate information about the client's physical state and a biofeedback technician to interpret the results.

15. A 27-year-old client was diagnosed 5 years ago with schizophrenia. What course of treatment should the nurse expect to be implemented? A. Eventual admission for long-term care in a psychiatric facility B. Community-based care with numerous brief hospitalizations C. Case management in the community with few relapses D. Occasional contact with outpatient counselors and psychiatrists

ANS: B Community-based care is the standard of treatment that followed the deinstitutionalization movement. Schizophrenia is a chronic disease that includes both exacerbations and remissions in the course of the illness, leading to numerous brief hospitalizations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

13. A community health nurse is teaching a class to expectant parents. All participants lack infant care knowledge. A student nurse asks, If you had to assign a nursing diagnosis to this group, what would it be? What is the best nursing reply? A. I would assign the nursing diagnosis of cognitive deficit. B. I would assign the nursing diagnosis of knowledge deficit. C. I would assign the nursing diagnosis of altered family processes. D. I would assign the nursing diagnosis of risk for caregiver role strain.

ANS: B Knowledge deficit is defined as the absence or deficiency of cognitive information related to a specific topic. Cognitive deficit would indicate an alteration in the ability to process information, and this evidence is not provided in the question. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Health Promotion and Maintenance

A nurse is teaching a client deep breathing exercises. The client asks, "Why do I need to make that funny shape with my lips when I breathe out?" What is the most appropriate nursing reply? A. "You can actually exhale anyway you like; the lip shape is not important." B. "Pursed lip breathing helps you control the exhalation and helps to keep your airways open." C. "Don't worry about the lip shape; concentrate instead on the pace of your breathing." D. "The shape of the lip decreases the cough and choking reflex."

ANS: B Pursed lip breathing is controlled, allowing for longer exhalation because it is more effective in keeping the airways open.

10. A client diagnosed with schizophrenia is hospitalized because of an exacerbation of psychosis related to antipsychotic medication nonadherence. Which level of care does the clients hospitalization reflect? A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care

ANS: B The clients hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

3. A nursing instructor is teaching about case management. What student statement indicates that learning has occurred? A. Case management is a method used to achieve independent client care. B. Case management provides coordination of services required to meet client needs. C. Case management exists to facilitate client admission to needed inpatient services. D. Case management is a method to facilitate physician reimbursement.

ANS: B The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that specific outcomes are achieved within allotted time frames. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

12. A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. What disease that has recently become more prevalent among the homeless community should a nurse suspect? A. Meningitis B. Tuberculosis C. Encephalopathy D. Mononucleosis

ANS: B The nurse should suspect that the homeless client has contracted tuberculosis. Tuberculosis is a growing problem among homeless individuals because of being in crowded shelters, which are ideal conditions for the spread of respiratory tuberculosis. Alcoholism, drug addiction, HIV infection, and poor nutrition also contribute to the increase in cases of tuberculosis. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

23. The nurseclient therapeutic relationship includes which of the following characteristics? Select all that apply. A. Meeting the psychological needs of the nurse and the client B. Ensuring therapeutic termination C. Promoting client insight into problematic behavior D. Collaborating to set appropriate goals E. Meeting both the physical and psychological needs of the client

ANS: B, C, D, E The nurseclient therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. The nurses psychological needs should not be addressed within the nurseclient relationship.

18. Which of the following clients should a nurse recommend for a structured day program? Select all that apply. A. An acutely suicidal teenager who has had three previous suicide attempts B. A chronically mentally ill woman who has a history of medication noncompliance C. An elderly individual with end-stage Alzheimers disease D. A depressed individual who is able to participate in a safety plan E. A client who is hearing voices that tell him or her to harm others

ANS: B, D The nurse should recommend a structured day program for a chronically mental ill woman who has a history of medication noncompliance and for a depressed individual who is able to participate in a safety plan. Day programs (also called partial hospitalizations) are designed to prevent institutionalization or to ease the transition from inpatient hospitalization to community living. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment: Management of Care

4. John, a homeless person, has just come to live in the shelter. The shelter nurse is assigned to his care. Which of the following is a priority intervention on the part of the nurse? a. Referring John to a social worker b. Developing a plan of care for John c. Conducting a behavioral and needs assessment on John d. Helping John apply for Social Security benefits

ANS: C

7. Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W., a 78-year-old widow who lives alone. Mrs. W.'s primary care physician has diagnosed her as depressed. Which of these potential problems is a priority to evaluate for during the first home visit? a. Complicated grieving b. Social isolation c. Risk for injury d. Sleep pattern disturbance

ANS: C

9. A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication

ANS: C Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive self-regard. Clients who are utilizing defensive coping lack assertiveness skills.

19. A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, I worked last Christmas and will not work this Christmas. When the supervisor says But I need you to work, the nurse repeats I worked last Christmas and will not work this Christmas. This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for ones basic rights C. Responding as a broken record D. Defusing

ANS: C Responding as a broken record is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted.

21. Which client statement indicates that termination of the therapeutic nurseclient relationship has been handled successfully? A. I know I can count on you for continued support. B. I am looking forward to discharge, but I am surprised that we will no longer work together. C. Reviewing the changes that have happened during our time together has helped me put things in perspective. D. I dont know how comfortable I will feel when talking to someone else.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals.

14. A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse? A. The client is using manipulation to receive secondary gain. B. The client is using the defense mechanism of denial. C. The client is having trouble terminating the relationship. D. The client is using splitting as a way to remain dependent on the nurse.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident.

8. Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurseclient relationship? A. I cant bear the thought of leaving here and failing. B. I might have a hard time working with you. You remind me of my mother. C. I cant tell my husband how I feel; he wouldnt listen anyway. D. Im not sure that I can count on you to protect my confidentiality.

ANS: C The nurse should identify that the client statement I cant tell my husband how I feel; he wouldnt listen anyway reflects resistance to change, which is a common behavior in the working phase of the nurseclient relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

6. What should be the nurses primary goal during the preinteraction phase of the nurseclient relationship? A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client change

ANS: C The nurses primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information.

20. A nurse has identified the following nursing diagnosis: ineffective communication R/T lack of assertiveness skills AEB inability to state needs. Which statement encourages the client to acknowledge the priority of this problem? A. Are you having thoughts of harming yourself or others? B. With whom are you least assertive? C. On a scale of 1 to 10, rank the importance of being assertive. D. When are you available to attend the assertiveness training class?

ANS: C This nursing statement encourages the client to objectively evaluate the priority of being assertive. It is important in patient-centered care for the client to prioritize his or her goals for treatment.

7. While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an I statement. Which of the following statements is the best example of this assertive communication technique? A. I would like to know why you came home late without calling me. B. I hate it when you think you can just come home late without calling anyone to let them know where you are. C. I feel angry when you come home late without calling. D. I think you dont care about me, because if you did, youd call me if you were planning on coming home late.

ANS: C This response clearly states feelings about a situation without blaming another.

17. The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, Are you upset because I believe in academic freedom or because you dont? The faculty member is using which technique to promote assertive behavior? A. Standing up for ones basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony

ANS: C This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements.

17. As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurses most therapeutic statement? A. I want to assure you that I will maintain your confidentiality. B. A long-term goal for someone your age would be to develop better job skills. C. Which identified problems would you like for us to initially address? D. I think first we need to focus on your relationship issues.

ANS: C When moving on a continuum from the orientation to working phase of the nurseclient relationship, the clients identified goals are addressed through mutual therapeutic work to promote client behavioral change.

1. A nursing instructor is teaching students about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? A. Many perspective clients did not meet criteria for mental illness diagnostic-related groups. B. Zoning laws discouraged the development of community mental health centers. C. States could not match federal funds to establish community mental health centers. D. There was not a sufficient employment pool to staff community mental health centers.

ANS: C A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effects of deinstitutionalization caused by the closing of state mental health hospitals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

Which response is known to be a physiological manifestation of relaxation? A. Increased levels of norepinephrine B. Pupil dilation C. Reduced metabolic rate D. Increased levels of blood sugar

ANS: C During relaxation, the metabolic rate decreases.

A client asks a nurse what is the difference between modified (or passive) progressive relaxation and progressive relaxation. Which is the most appropriate nursing reply? A. "There is an increased focus on deep breathing in the modified version." B. "Only large muscle groups are targeted in the modified version." C. "There is no muscle contraction in the modified version." D. "The modified version is for clients with preexisting cardiovascular disease."

ANS: C In modified (or passive) progressive relaxation, the muscles are not tensed before relaxing them.

The nurse should recognize that improvement in concentration and attention occurs with which relaxation technique? A. Biofeedback B. Physical exercise C. Meditation D. Mental imagery

ANS: C Meditation has been found to improve concentration and attention.

Which positive physical benefit would relaxation provide for a client who has experienced stress-related asthma? A. Decreased neurotransmitters B. Decreased blood pressure C. Increased oxygen saturation levels D. Decreased alpha brain waves

ANS: C Relaxation results in increased lung capacity and stable respiratory rate leading to increased oxygen saturation levels.

7. A newly admitted homeless client diagnosed with schizophrenia states, I have been living in a cardboard box for 2 weeks. Why did the government let me down? Which is an appropriate nursing reply? A. Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless. B. Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia. C. Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success. D. Your discharge from the state hospital was based on presumed family support, and this was not forthcoming.

ANS: C The most accurate nursing reply is to explain to the client that the resources were not available for successful transitioning out of a state hospital to the community. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

2. A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care? A. Teaching an adolescent about pregnancy prevention B. Teaching an elderly client the reportable side effects of a newly prescribed neuroleptic medication C. Teaching a client with schizophrenia to cook meals, make a grocery list, and establish a budget D. Teaching a client about his or her new diagnosis of bipolar disorder

ANS: C The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention is services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by promoting rehabilitation that is directed toward achievement of maximum functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

9. When a home health nurse administers an outpatients injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing? A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care

ANS: C When administering this long-acting antipsychotic medication, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation directed toward achievement of maximum functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

16. Which intervention should the nurse consider as primary prevention for an individual who is on the verge of being homeless because of a job layoff? A. Referral to primary care provider to improve general health status B. Encouraging client to recognize reasons for job layoff C. Job training to increase employment options D. Encouraging the use of prn medications to control symptoms

ANS: C When the nurse implements primary prevention interventions, the nurse is providing services aimed at reducing the incidences of mental disorders within the population. In this situation, there is emphasis on providing education and support to unemployed or homeless individuals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

5. John, a homeless person, has a history of schizophrenia and nonadherence to his medication regimen. Which of the following medications might be the best choice for John? a. Haldol b. Navane c. Lithium carbonate d. Prolixin decanoate

ANS: D

8. Mrs. W., a 78-year-old depressed widow, says to her home health nurse, "What's the use? I don't have anything to live for anymore." Which is the best response on the part of the nurse? a. "Of course you do, Mrs. W. Why would you say such a thing?" b. "You seem so sad. I'm going to do my best to cheer you up." c. "Let's talk about why you are feeling this way." d. "Are you having thoughts about harming yourself in any way?"

ANS: D

15. According to Peplau, which nursing action demonstrates the nurses role as a resource person? A. The nurse balances a safe therapeutic environment to increase the clients sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of cheeking. D. The nurse explains, in language the client can understand, information related to the clients health care.

ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem.

13. Which is the most appropriate nursing reply when a client asks what the goal and benefit are of assertive skills training? A. It protects the client from others who express aggressive feelings. B. It gives reliable, expert information so that clients may correct faulty behaviors. C. It clarifies misperceptions that have caused clients to distort reality. D. It improves communication skills in order to improve interpersonal relationships.

ANS: D Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to communicate in a manner to meet their own needs while respecting the rights and needs of others.

22. When is self-disclosure by the nurse appropriate in a therapeutic nurseclient relationship? A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client

ANS: D Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurses needs.

22. A client is experiencing high stress. The client states, My boss treats me like a doormat and thinks nothing of demanding frequent overtime. Which nursing intervention would be appropriate? A. To incorporate the family support system into the clients plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use I statements

ANS: D The ability to use I statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training.

12. On which task should a nurse place priority during the working phase of relationship development? A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the clients insight and perception of reality

ANS: D The nurse should place priority on promoting the clients insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

3. Which is the best nursing action when a client demonstrates transference toward a nurse? A. Promoting safety and immediately terminating the relationship with the client B. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurseclient relationship

ANS: D The nurse should respond to a clients transference by clarifying the meaning of the nurseclient relationship, based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present.

10. A mother who has learned that her child was killed in a tragic car accident states, I cant bear to go on with my life. Which nursing statement conveys empathy? A. This situation is very sad, but time is a great healer. B. You are sad, but you must be strong for your other children. C. Once you cry it all out, things will seem so much better. D. It must be horrible to lose a child; Ill stay with you until your husband arrives.

ANS: D The nurses response, It must be horrible to lose a child; Ill stay with you until your husband arrives, conveys empathy to the client. Empathy is the ability to see the situation from the clients point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

5. During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. Several techniques, including meditation and progressive muscle relaxation, appear helpful. B. Theres not much that can be done about aggressive behavior because of biological responses. C. Certain types of medications have been proven effective in promoting assertive communication. D. There are several techniques, including I statements, role playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors.

ANS: D These techniques promote assertive behaviors and would help diminish aggressive responses.

12. Which best describes a nurses use of assertive behavior? A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments

ANS: D This is an assertive response. There is clear expression of needs and feelings.

14. An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. The right to be treated with respect is an assertive right. B. The right to say no without feeling guilty is an assertive right. C. The right to change your mind is an assertive right. D. The right to always put oneself first is an assertive right.

ANS: D This is not an assertive right. An assertive right is to consider others as well as yourself. This student statement indicates a need for further instruction.

3. A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. Client is displaying assertive behaviors. B. Client is displaying aggressive behaviors. C. Client is displaying passive behaviors. D. Client is displaying passive-aggressive behaviors.

ANS: D This response is passiveaggressive. The clients anger is expressed indirectly by spitting in the soup when the peer is not looking.

8. After vying for a nurse management position, nurse A is chosen over nurse B. When nurse manager A calls for staff meetings, nurse B is chronically late or absent. Nurse B is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passiveaggressive

ANS: D This response is passiveaggressive. The colleague is expressing anger indirectly by being late or absent from the meetings.

18. An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. What is the real reason that you dont want the schedule changed? B. Sounds to me like youre threatened by this change. C. Are you upset because you dont want to redo the schedule? D. I have the right to express my opinion about the schedule.

ANS: D This response reflects the use of standing up for ones basic human rights.

11. When a nurse attempts to provide health-care services to the homeless, what should be a realistic concern? A. Most individuals who are homeless reject help. B. Most individuals who are homeless are suspicious of anyone who offers help. C. Most individuals who are homeless are proud and will often refuse charity. D. Most individuals who are homeless relocate frequently.

ANS: D A realistic concern in the provision of health-care services to the homeless is that individuals who are homeless relocate frequently. Frequent relocation confounds service delivery and interferes with providers efforts to ensure appropriate care. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

14. A client diagnosed with schizophrenia was released from a state mental hospital after 20 years of institutionalization. A nurse should recognize which characteristic that is likely to be exhibited by this client? A. The client is likely to be compliant with treatment because of institutional dependency. B. The client is likely to find a variety of community support services to aid in the transition. C. The client is likely to adjust to the community environment if given sufficient support. D. The client is likely to be admitted at some time to an acute care unit for psychiatric treatment.

ANS: D Because of the chronic nature of this clients diagnosis and commonly occurring medication noncompliance, the nurse would expect recidivism during the course of the illness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

5. When intervening with a married couple experiencing relationship discord, which reflects a nursing intervention at the secondary level of prevention? A. Assessing how the children are coping with the parents relationship issues B. Supplying the couple with guidelines related to marital seminar leadership C. Teaching the couple about various methods of birth control D. Counseling the couple in relation to open and honest communication skills

ANS: D Counseling the couple in relation to open and honest communication skills is reflective of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client who has been undergoing stress management training asks a nurse how long practicing stress reduction should last. Which is the most appropriate nursing reply? A. "Until this stressor has resolved." B. "Usually it takes several months before stress is eliminated." C. "Whenever you feel better, you can stop." D. "Managing stress is a lifelong function."

ANS: D Management of stress must be considered a lifelong function. Nurses can help individuals recognize the sources of stress in their lives and identify methods of adaptive coping.

During a psychoeducational group on stress management, a client asks about meditation. Which nursing statement is most accurate regarding meditation? A. "It is a procedure whereby various muscle groups are contracted and relaxed, bringing about an overall sense of relaxation." B. "The procedure is one whereby you use your imagination to relax and reduce the tension in your body." C. "The purpose is to become aware of one's bodily processes and to bring them under conscious control." D. "The goal is to gain mastery and control over one's attention, bringing about a special state of consciousness."

ANS: D Meditation creates a special state of consciousness because attention is concentrated on one thought or object.

Which should a nurse recognize as the reason that physical exercise is an effective relaxation technique? A. Physical exercise stresses and strengthens the cardiovascular system. B. Physical exercise decreases the metabolic rate. C. Physical exercise decreases levels of norepinephrine in the brain. D. Physical exercise provides a natural outlet for releasing muscle tension.

ANS: D Physical exercise is an effective relaxation technique because it provides a natural outlet for releasing muscle tension produced by the body when stressed.

8. A nursing instructor is teaching students about the differences between partial and inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient hospitalization? A. Partial hospitalization does not provide medication administration and monitoring. B. Partial hospitalization does not use an interdisciplinary team. C. Partial hospitalization does not offer a comprehensive treatment plan. D. Partial hospitalization does not provide supervision 24 hours a day.

ANS: D The instructor should explain that partial hospitalization does not provide supervision 24 hours a day. Partial hospitalization programs generally offer a comprehensive treatment plan formulated by an interdisciplinary team. This has proved to be an effective method of preventing hospitalization. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

17. Which nursing statement best describes the current nature of mental health care in the community? A. All homeless people have a history of institutionalization and are frequently admitted to acute care settings. B. In the United States, the rate of serious mental illness in the prison population is the same as the general population. C. The deinstitutionalization movement in the United States was successful in transitioning clients into the community. D. Today, the majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization.

ANS: D The majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization and reintroduction into the community. Crisis situations can occur because of treatment noncompliance and exacerbations of the chronic mental illness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity Multiple Response

A nurse is caring for a client who has suffered a stress-related myocardial infarction. Which client statement indicates that the client is ready to learn about the relationship of stress to physical illness? A. "I just need to take my blood pressure medication religiously." B. "The first thing I will do, will be to cut down on my smoking." C. "My father had six heart attacks and survived them all. I plan to do the same." D. "I eat well and exercise. What else do you think could have led to my heart attack?"

ANS: D This response shows that the client is seeking information to improve his health and signals openness to change.