481 HESI

A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction? A. Stay at the bedside with the family and the deceased B. Direct activities related to funeral arrangements C. Mobilize the support systems for the family D. Present the full reality of the loss to the family

A. Stay at the bedside with the family and the deceased

Which defense mechanism would the nurse conclude a female client with obsessive-complusive disorder who washes her hands more than 20 times a day using to ease anxiety? A. Undoing B. Projection C. Introjection D. Displacement

A. Undoing

Which nursing actions best promote communication when obtaining a nursing history? SATA A. Establishing eye contact B. Paraphrasing the clients message C. Asking"why" and "how" questions D. Using broad, open-ended statements E. Reassuring the client that there is no cause for alarm F. Asking questions that can be answered with a "yes" or "no"

A. Establishing eye contact B. Paraphrasing the clients message D. Using broad, open-ended statements

Which phenomenon would the client be experiencing when the client looks at a linen sheet on a clothesline and thinks it is a ghost? A. Illusion B. Delusion C. Hallucination D. Confabulation

A. Illusion

Which medications are used at the first-line treatment for post-traumatic stress disorder (PTSD)? STAT A. Sertraline B. Paroxetine C. Phenelzine D. Venlafaxine E. Amitriptyline

A. Sertraline B. Paroxetine

A client, diagnosed with borderline personality disorder, declares that the whole staff is "bad" after being disappointed by one staff member. Which defense mechanism is the client using? A. Splitting B. Rationalization C. Undoing D. Reaction formation

A. Splitting

Which questions would the nurse ask when, during the assessment of an older adult, the nurse suspect suicidal intent? SATA A. "Do you think about killing yourself" B. "How often do you have these thoughts" C. "Do you have the means to kill yourself" D. "Have you thought about your loved ones" E. "How would you kill yourself if you decided to do it" F. "Why do you think you wont be around much longer"

A. "Do you think about killing yourself" B. "How often do you have these thoughts" C. "Do you have the means to kill yourself" E. "How would you kill yourself if you decided to do it"

Which question would the nurse ask to the test the older adult clients capacity for abstract thinking? A. "How are a television and a radio alike" B. "Can you give me todays complete date" C. "What would you do if you fell and hurt yourself" D. Repeat the following numbers for me: 8, 3, 7, 1, 5"

A. "How are a television and a radio alike"

Which statement demonstrates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship? A. "My clients and I are partners in the planning that helps meet their physical and mental health needs" B. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care to be provided" C. "Mental health is achieved and maintained when the nurses and clients exhibit respect and caring for each other" D. "Without a mutually satisfying relationship between nurse and client, achieving mental and physical wellness is very difficult"

A. "My clients and I are partners in the planning that helps meet their physical and mental health needs"

Which response would the nurse make to a depressed client who was forced into early retirement and reports feeling useless and having nothing to do? A. "Tell me more about feeling useless" B. "Volunteering can help you fill your time" C. "Your illness is adding to your current feelings" D. "Lets talk about what you'd like to be doing right now."

A. "Tell me more about feeling useless"

A client who is scheduled for a muscle biopsy tells the nurse, "They better give me a general anesthetic. I dont want to feel anything." Which is the most therapeutic initial response by the nurse? A. "You seem to be worried about the test" B. "This test is done under local anesthesia" C. "Tell them when you have pain so they can take care of it" D. "You probably will not have pain so try not to think about it"

A. "You seem to be worried about the test"

Which behavior by the client exhibits denial after a recent diagnosis? A. Attempts to minimize the illness B. Lacks an emotional response to the illness C. Refuses to discuss the condition with the clients spouse D. Expresses displeasure with the prescribed activity program

A. Attempts to minimize the illness

A client with terminal cancer says to the nurse, "If i could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving would the nurse conclude the client is experiencing? A. Bargaining B. Frustration C. Depression D. Rationalization

A. Bargaining

Which therapeutic communication technique is demonstrated when the nurse says, "Im confused about exactly what is upsetting you. Would you go over that again, please?" A. Clarifying B. Structuring C. Confronting D. Paraphrasing

A. Clarifying

The objective of therapy group is to assist the members to change behavior so they are able to participate in life in a more satisfying manner. Which leadership style is best to achieve this objective? A. Democratic, guiding B. Hierarchial, directing C. Autocratic, controlling D. Laissez-faire, observing

A. Democratic, guiding

A survivor of a major earthquake exhibits a flattened affect, minimal eye contact, and monotone speech. Which defense mechanism is the survivor displaying? A. Disassociation B. Splitting C. Introjection D. Compensation

A. Disassociation

Which statement from the client would alert the nurse the client is experiencing a hallucination? A. "I am going to save the world because i am god" B. "My insides smell like they are going to just rot away" C. "Unless i gamble at least once a week, I feel extremely anxious" D. "Its crazy, but I keep thinking that something terrible will happen to my baby"

B. "My insides smell like they are going to just rot away"

Which response would the nurse make to a client with agitation and mood swings who shouts, "Ive been watching you for a few days. You think youre so perfect and good. I think you stink"? A. "Do you mean that I smell?" B. "You seem to be angry with me." C. "Wow, yourein a really bad mood" D. "I cant really be all that bad, can I?"

B. "You seem to be angry with me."

The clients give a long, drawn-out explanation with excessive and irrelevant detail before answering the nurse's question. Which mental process is the client displaying? A. Flight of ideas B. Circumstantiality C. Thought blocking D. Tangential thinking

B. Circumstantiality

The client reports screaming hysterically whenever a spider comes close to her. Which defense mechanism is the client using? A. Sublimation B. Displacement C. Repression D. Introjection

B. Displacement

Which speech pattern is a disturbed client displaying when they start to repeat phrases that other shave just said? A. Alogia B. Echolalia C. Neologism D. Symbolic speech

B. Echolalia

Which term would be used to document the client affect, which was observed during the mental status assessment? A. Depressed B. Flat C. Cooperative D. Resistive

B. Flat

Which consideration is of primary importance when planning for a therapy group? A. Age and ethnicity of clients in the group B. Needs of the clients being included C. Diagnoses of the clients being included D. Socioeconomic status of the clients

B. Needs of the clients being included

A client with schizophrenia repeatedly says, "No moley, jandu!" Which language disturbance is the client exhibiting? A. Echolalia B. Neologism C. Concretism D. Pereveration

B. Neologism

Which behavior indicates that the nurse may be experiencing countertransference with a client? A. Client likes to sit beside the nurse in group therapy B. Nurse feels angry when a spouse is terse with the client C. Client intentionally performs an action to get the nurse's attention D. Nurse must repeatedly remind the client to go to group therapy

B. Nurse feels angry when a spouse is terse with the client

A client sits huddled in a chair and later moves to assume the fetal position in a corner. Which defense mechanism is the client using? A. Displacement B. Regression C. Dissociation D. Reaction formation

B. Regression

An anxious client reports pain in the abdomen and feeling empty and hollow, but a diagnostic workup reveals no physical causes. Which term reflects what the client is experiencing? A. Dissociation B. Somatization C. Stress response D. Factious disorder by proxy

B. Somatization

A client says, "Sky, flower, angry, green, opposite, blanket." Which term describes this type of communication? A. Echolalia B. Word salad C. Confabulation D. Flight of ideas

B. Word salad

Which sedative-hypnotics would the nurse identify as being used to treat insomnia associated with a panic disorder? SATA A. Phenelzine B. Paroxetine C. Alprazolam D. Imipramine E. Clonazepam

C. Alprazolam E. Clonazepam

When a client and the family are informed about electroconvulsive therapy (ECT) as a treatment option, the family urges the client to agree. Which ethical principle is involved in this decision making? A. Justice B. Veracity C. Autonomy D. Beneficence

C. Autonomy

Which definition describes the defense mechanism of sublimation? A. Returning to an earlier, less mature stage of deployment B. Acting out a conscious behavior that is the opposite of unconscious feeling C. Channeling unacceptable impulses into socially appropriate behavior D. Excluding from consciousness thoughts that are psychology disturbing

C. Channeling unacceptable impulses into socially appropriate behavior

When discussing standards for involuntary admission to a mental health facility, which factor is related to safety? A. Mental illness B. Severe disability C. Currently cutting D. Needs treatment

C. Currently cutting

Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech? A. Touch B. Silence C. Focusing D. Summarizing

C. Focusing

A women is afraid of the water, and she insists her teenage son doesn't want to go swimming or boating with his friends. Which defense mechanism is she displaying? A. Disassociation B. Introjection C. Projection D. Reaction formation

C. Projection

A female client tells the nurse that she hates her roommate. Later, the client tells the roommate, "I missed you. Where have you been?" Which defense mechanism the client using? A. Projection B. Sublimation C. Reaction formation D. Compensation

C. Reaction formation

Which defense mechanism is a client displaying when the client can no longer remember why an event was stressful, even though it happened just 3 days ago? A. Denial B. Regression C. Repression D. Dissociation

C. Repression

The nurse says, "Let's see whether we both mean the same thing." Which communication technique is the nurse using? A. Reflecting feelings B. Making observations C. Seeking consensual validation D. Placing events in sequence

C. Seeking consensual validation

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? A. Making a huge efforts to avoid "any kind of bug or spider" B. Experiencing flashbacks to an event that involved a sexual attack C. Spending hours each day worrying about something "bad happening" D. Becoming suddenly tachycardic and diaphoretic for no apparent reason

C. Spending hours each day worrying about something "bad happening"

Which defense mechanism is considered a conscious measure that is used to cope with anxiety? A. Undoing B. Projection C. Suppression D. Intellectualization

C. Suppression

Which statement by the nurse indicated understanding of the DSM-5 criteria for post-traumatic stress disorder (PTSD)? A. "Feelings of self-worth remain high" B. "PTSD does not occur in children younger than 6 years of age" C. "Clients will remember all details of the event" D. "Flashbacks must last for longer than 1 month"

D. "Flashbacks must last for longer than 1 month"

An older client is able to preform activities of daily living, but has vague physical complaints and has experienced multiple deaths of friends and family and has lost their social roles. Which questionis the most therapeutic? A. "Can you cope with being alone" B. "Have you considered assisted living" C. "What is the main problem today" D. "How do you feel about your life now"

D. "How do you feel about your life now"

A client who is hospitalized with severe abdominal pain and vomiting states, "I know I am very sick. Do you think I have a cancer?" How would the nurse respond? A. "You must be upset to think that you have cancer" B. "Did you receive information about which therapy will be prescribed?" C. "Your primary health care provider will need to talk with you about that." D. "What are your feelings about the diagnosis of cancer?"

D. "What are your feelings about the diagnosis of cancer?"

Which response by the nurse uses the technique of paraphrasing when after receiving chemotherapy for non-Hodgkin lymphoma, a client states, "I get so sick to my stomach. The medication is useless." ? A. "You get sick to your stomach" B. "Tell me more about how you feel" C. "Ill get a prescription for an antiemetic" D. "You dont think the medication is helping you"

D. "You dont think the medication is helping you"

Which intervention would the nurse include in the initial plan of care for a client with the long-standing obsessive complusive behavior of hand washing? A. Determine the purpose of the ritualiatic behavior B. Limit the time allowed for the ritualistic behavior C. Suggest a symptom-substitution technique D. Develop a routine schedule of activities

D. Develop a routine schedule of activities

Which factor is most important in predicting a persons reaction to imminent loss and grief? A. Family interactions B. Social support system C. Emotional relationships D. Earlier experiences with grief

D. Earlier experiences with grief

Which benefit is provided by milieu therapy? A. Availability of individual and family therapy B. Positive reinforcement to reduce guilt C. Revelation of unconscious conflicts and fantasies D. Environment provides structure, routine, and security

D. Environment provides structure, routine, and security

Which communication technique is a part of therapeutic communication? A. Asking for explanations B. Showing sympathy to the client C. Asking personal questions of the client D. Providing relevant information to the client

D. Providing relevant information to the client

A client says, "Since my husband died, i've got nothing to live for. I just want to die." The unlicensed assistive personnel (UAP) says, "Things will get better soon." Which communication error has occurred? A. Offering advice B. Belittling the client C. Changing the subject D. Proving false reassurance

D. Proving false reassurance

A person with a history of alcoholism says "Ive been drinking since last Friday to celebrate my son's graduation from college." Which defense mechanism is the person displaying? A. Denial B. Projection C. Identification D. Rationalization

D. Rationalization

The nurse is caring for a group of clients on the psychiatric unit. Which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? A. Continuous involuntary movements of the tongue and jaw B. Extremely high blood pressure with headache and flushing C. Blurred vision, urine retention, dry mouth, and constipation D. Restlessness, tachycardia, fever, diarrhea, and altered mental status

D. Restlessness, tachycardia, fever, diarrhea, and altered mental status

An older client describes the current situation and then offers information that goes further and further off the topic. Which pattern of communication is the client using? A. Preservation B. Thought blocking C. Pressured speech D. Tangential thinking

D. Tangential thinking

Which legal implication would the nurse understand about applying restraints to a client? A. The law allows restraining clients until a written prescription is obtained B. A felony charge may be leveled against nurses who use any kinds of restraints C. Nurses are not obligated to report institutions that use restraints unlawfully D. The nurse can be charged with assault and battery for using restraints improperly

D. The nurse can be charged with assault and battery for using restraints improperly