EAQ #1 for mental health

interpersonal communication

one on one communication between a nurse and another person

perseveration is what

repetitive verbalizations or motions

after a laryngectomy is scheduled what is the most important factor for the nurse to include the preoperative teaching plan a. establishing a means for communicating postoperatively b. explaining that there will be a feeding postoperatively c. demonstrating how to care for a permanent laryngeal stoma d. teaching how to cough to expectorate bronchial secretions effectively

a. establishing a means for communicating postoperatively

the parents of an adolescent girl are upset about their daughters diagnosis of anorexia nervosa and the treatment plan that has been proposed. what is the best response by the nurse when the clients parents ask to bring food in for the client? a. for now let the staff handle her food needs b. your concerns about food contribute to her prob c. while shes in the hospital she could eat the hospital food d. it's important for you to bring in anything that you think she'll eat

a. for now let the staff handle her food needs

a client is admitted for surgery although not physically distressed the client appears apprehensive (anxious) and withdrawn. what is the nurses best action? a. orient the client to the unit environment b. have a copy of hospital regulations available c. explain that there is no reason to be concerned d. reassure the client that the staff is available if the client has questions

a. orient the client to the unit environment

RN evaluates a newly hired nurses understanding of sexual changes in older men which statements made by the newly hired nurse indicate a need for further teaching? select all that apply a. sperm production stops in old age b. sexual interest doesnt continue in later life c. testosterone production decreases in later yrs d. the ability to procreate diminishes in the 8th decade

a. sperm production stops in old age b. sexual interest doesnt continue in later life d. the ability to procreate diminishes in the 8th decade

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? a. stating wishes verbally b. recognizing familiar objects c. comprehending written words d. understanding verbal communication

a. stating wishes verbally

a client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. what information about the clients activities in the history indicates to the nurse there is a need for this test? a.the client takes care of a cat b. the client works as a dog trainer c. the client uses chemical cleaners d. the client consumes raw veggies

a. the client takes care of a cat

a client in the emergency department is diagnosed with atrial fibrillation. initially the primary HCP instructs the client to perform the valsava maneuver by holding the breath and bearing down. what should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm? a. the vagus nerve is stimulated b. the glottis closes momentarily c. thoracic pressure decreases d. respiratory pattern is interrupted

a. the vagus nerve is stimulated

When a client who had a mastectomy sees her incision for the first time, she exclaims, "I look horrible! Will it ever look better?" What is the nurse's best response? a. you looked shocked by the way you look now b. now that the tumor is gone the area will heal quickly c. after it heals others wont even know you had surgery d. you will feel better about it when the swelling subsides

a. you looked shocked by the way you look now

client who is to have sclerotherapy asks the nurse how did i get varicose veins? which etiology should the nurse take into consideration when formulating a response? a. short episodes of standing b. defective valves w/in the veins c. compressions of leg muscles on the veins d. formation of thrombophlebitis in the veins

b. defective valves w/in the veins

a disturbed client starts to repeat phrases that others have just said. how should the nurse document this speech? a. alogia b. echolalia c. neologism d. echopaxia

b. echolalia

a client is telling a nurse what she does to maintain her health which statements made by the client indicate she sticks primarily to an alternative or complementary health belief system? a. i usually take laxative to relieve constipation b. i often use topical essential oils to promote relaxation c. i believe in treatment that involves carrying out rituals d. i believe acupuncture is most effective in relieving pain e. i frequently practice meditation to keep myself from becoming depressed

b. i often use topical essential oils to promote relaxation d. i believe acupuncture is most effective in relieving pain e. i frequently practice meditation to keep myself from becoming depressed

the practical nurse is discussing the basic rules of documentation with a group of nursing students. which statements made by a nursing student indicate a need for further discussion? a. i should chart only what i hear, see, and smell b. i should include all my opinions in the document c. i should not indent left margin while documenting d. i should chart before and after i care for the client e. i should use only approved abbv while documenting

b. i should include all my opinions in the document d. i should chart before and after i care for the client

a thallium scan is scheduled for a client who had a myocardial infarction. what should the nurse explain to the client regarding the reason the scan has been prescribed? a. that it will monitor the mitral and aortic valves b. that it establishes the viability of myocardial muscle c. that it can visualize the ventricular systole and diastole d. that it will determine the adequacy of electrical conductivity

b. that it establishes that viability of myocardial muscle

During a phone conversation a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse? a."Is there anyone there with you?" b."What do you think this means?" c. "How do you usually handle this type of situation?" d. "What's happening right now that prompted you to call?"

d. "What's happening right now that prompted you to call?"

a nurse assigned to care for a college student who has been talking to unseen and refusing to get out of bed, go to class, or get involved in daily grooming activities. What is the nurse's initial effort toward helping this client? a. providing frequent rest periods b. reducing environmental stimuli c. facilitating the clients social relationships with peer group d. attempting to establish a meaningful relationship with the client

d. attempting to establish a meaningful relationship with the client

after conversing with a peer nurse who is delegating a task the nurse suspects the peer nurse is an autocratic leader (make decision for everyone). which statement of the peer nurse would lead to this conclusion? a. i guide my co-team members simultaneously when required b. i treat my team members equally important while making a decision c. i ask my team members to feel free to express their opinion while making decisions d. i have the power to intimidate any team members who fail to adhere to expectations

d. i have the power to intimidate any team members who fail to adhere to expectations

What response from the nurse demonstrates an understanding of hallucinating behavior by a client? a. asking " what are the voices telling you to do?" b. calmly noting that the rat on the floor is a stuffed toy c. allowing the family to bring prepackaged foods from the store

a. asking " what are the voices telling you to do?"

a nurse documents the blood glucose levels before and after the administration of insulin and finds improvement in the clients condition. which format of SOAPER describes this documentation? a. revision b. evaluation c. assessment d. objective info

b. evaluation

A client spends several minutes making negative comments to the nurse about numerous aspects of the hospital stay. What is the nurse's best initial response? a. Describe the purpose of different hospital therapies to decrease the client's anxiety. b. Explain that becoming so upset does not allow the client to get much-needed rest. c. Refocus the conversation on the client's fears, frustrations, and anger about the condition. d. Permit the client to release feelings and then leave the room to allow the client to regain composure.

c. Refocus the conversation on the client's fears, frustrations, and anger about the condition.

During the activation of an emergency preparedness plan, which individual should communicate with the media? a. medical director b. emergency department nurse c. director of human resources d. hospital chief executive officer

c. director of human resources

A client who is terminally ill appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response? a. why are you always telling joke b. your laughter is a cover for your fear c. does it help to joke about your illness d. the one who laughs on the outside cries in the inside

c. does it help to joke about your illness

A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? 1 "A location that requires no decision-making will resolve feelings of anxiety." 2 "The daycare setting allows the staff to exert control over unacceptable behaviors." 3 "A neutral atmosphere facilitates the working through of conflicts." 4 "This environment limits time to carry out the rituals."

2 "The daycare setting allows the staff to exert control over unacceptable behaviors."

a couple interested in family planning asks the nurse about the cervical mucus method of family planning. the nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is what? a. clear and thick b. yellow and thin c. cloudy and viscid d. clear and stretchable

d. clear and stretchable

a client with a history of angina is scheduled for a cardiac catheterization. catheter entry will be through the femoral artery. what should the nurse tell the client to expect? a. remain fully alert during the procedure b. ambulate shortly after the procedure c. experience a feeling of warmth during the procedure d. be placed in a semi fowler position for 12 hrs after the procedure

c. experience a feeling of warmth during the procedure

a nurse in the facility clinic works with couples who have been trying to become pregnant for more than 1 year. how can the nurse help ease the feeling of isolation that infertile couples often experience? a. teach them about infertility and its treatment b. identify activities that are interesting and satisfying c. explore ways to promote communication with family and friends d. explain to them that men and women cope differently with stressful situations

c. explore ways to promote communication with family and friends

a pregnant client whose first child has down syndrome is about to undergo amniocentesis. the client tells the nurse that she does not know what she will if this fetus has the same diagnosis. the client asks the nurse, "do you think abortion is the same as killing?" how should the nurse respond? a. some people think that thats what an abortion is b. no i dont think so but its your decision c. i really cant answer that question. are you ambivalent (mixed feelings) about abortion? d. i dont want to answer that question at this time. how do you feel about it?

c. i really cant answer that question. are you ambivalent (mixed feelings) about abortion?

the practical nurse is discussing with the group of nursing students the guidelines for safe computer documentation. which statements made by the nursing students indicate the need for further discussion? select all that apply a. i should protect the computerized printouts b. i should follow the correct protocol for correcting errors c. i should share the password with another caregiver in my absence d. i should follow the agency confidentiality procedure for documentation e. i should leave the information about the client displayed for another caregiver to see

c. i should share the password with another caregiver in my absence e. i should leave the information about the client displayed for another caregiver to see

at times a clients anxiety level is so high that it blocks attempts at communicating and the nurse is unsure of what is being said. to clarify understanding the nurse says, "let's see whether we mean the same thing." what communication is being used by the nurse a.reflecting feelings b. making observations c. seeking consensual validation d. attempting to place events in sequence

c. seeking consensual validation

After giving birth to her third child, a client tearfully says to the nurse, "How much more can I give of myself?" What principle should the nurse consider in the care of any person with children a. it is easier to adjust to the first child than the other ones b. feeling anger and resentment toward a child is pathologic c. some parents experience feelings of being overwhelmed by multiple children d. parents usually have inborn feelings of love and acceptance of their children

c. some parents experience feelings of being overwhelmed by multiple children.

the nurse is performing a neurologic assessment on a client and is completing the glasgow coma scale what components make up this assessment tool? a. best verbal response b. best pupillary response c. best motor response d. best eye-opening response e. best cognitive response

a. best verbal response c. best motor response d. best eye-opening response

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." The nurse's initial response should be to: a. discuss the clients concerns b. clarify the misconception c. explain measure to prevent pulmonary emboli d. teach recognition of early symptoms of pulmonary emboli

a. discuss the clients concerns

When having a conversation with a nurse, an older client states, "I've lived a good life. I don't want to die, but I accept it as a part of life." What developmental stage, according to Erikson, has the client completed? a. Identity b. Integrity c. Acceptance d. Generativity

b. integrity

a nurse needs to record a clients data from admission until discharge. which record will the nurse use? a. acuity record b. source record c. hand-of records d. problem oriented medical record

b. source record

a nurse is teaching a class of premenopausal women how to perform breast self examination correctly. what is the optimal time of the month for breast self examination? a. when ovulation happens b. the first day of every month c. the day that the menses begins (blood discharge) d. about a week after menses ends

d. about a week after menses ends

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? a. "you are worried about paying your bills?" b. "Don't worry; your bills will get paid eventually" c. When was the last time you were admitted for hyperglycemia? d. "You really shouldn't be drinking alcohol because of your Dx of diabetes"

a. "you are worried about paying your bills?"

a client with phosphate based urinary calculi asks why aluminum hydroxide gel has been prescribed. the nurse explains that the medication decreases serum phosphorus by which action? a. binding with phosphorus in the intestine b. preventing absorption of phosphorus in the stomach c. promoting excretion of excessive urinary phosphorus d. dissolving stones as they pass through the urinary tract

a. binding with phosphorus in the intestine stops the absorption

depressed client tells a nurse " i want to die" what is the most therapeutic response by the nurse a. you would rather not live b. youre not alone in feeling this way c. when was the last time you felt this way d. do you believe that theres life after death?

a. you would rather not live

a client with varicose veins asks a nurse what's involved when ligation and stripping are performed rather than sclerotherapy. what should the nurse consider when planning a response in language the client will understand? a. plaque from within the veins is abraded b. the dilated saphenous veins are removed c. superficial veins are anastomosed to deep veins d. an umbrella filter is placed in the large affected veins

b. the dilated saphenous veins are removed

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse? a. maybe tomorrow you'll feel more like talking b. could you start off by talking about your family c. a person like you has a great deal to offer the group d. you feel you won't be accepted unless you have something to say?

d. you feel you won't be accepted unless you have something to say?

A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include? a. myomectomy b. hysterectomy c. salpingectomy d. oophorectomy

c. salpingectomy

while the nurse is at the beside of a client in acute renal failure, the client states, "my HCP said that i will be getting some insulin. do i also have diabetes?" what is the best nursing response? a. no the insulin will help your body handle the increased potassium levels b. i suggest that you ask your HCP that question c. you probably had an elevated blood glucose level so your HCP is being cautious d. no but insulin will reduce the toxins in your blood by lowering your metabolic rate

a. no the insulin will help your body handle the increased potassium levels bc insulin promotes the transfer of potassium into cells which reduces the circulating blood level of potassium

the preoperative nurse is reviewing a childs history and physical before repair of a ventricular septal defect. which assessment finding should the nurse expect? a. severe cyanosis b. high hemoglobin and hematocrit levels c. bilateral lung sounds with rales and rhonchi d. high BP in arms and low BP in legs

c. bilateral lung sounds with rales and rhonchi

a couple discovers that their neighbor has an autocratic family pattern. which statement made by the neighbor would lead to this conclusion? a. i make all the decisions for the family and manage all the finances b. i give strict punishment to my child for goofing off for more than one hour c. my spouses mother takes care of our child because she currently works

b. i give strict punishment to my child for goofing off for more than one hour

a nurse is teaching the parents of malnourished 6 year old child with celiac disease about foods and nutrients that will help correct a problem related to celiac disease. which foods and nutrients should the nurse recommend for this child? a. high-calorie foods rich in protein and fat to correct weight loss b. foods high in folic acid, iron, and vitamin b12 to correct anemia c. supplements of vitamins A,D,E and K to correct coagulation deficiencies d. foods high in potassium and magnesium to correct bone growth deficiencies

b. foods high in folic acid, iron, and vitamin B12 to correct anemia

a nurse is caring for an older adult with a hearing loss secondary to aging. what can the nurse expect to identify when assessing this client (select all that apply) a. dry cerumen b. tears in the tympanic membrane c. difficulty hearing high-pitched voices d. decrease of hair in the auditory canal e. overgrowth of the epithelial auditory lining

a. dry cerumen c. difficulty hearing high-pitched voices

Antipsychotic drugs can cause extrapyramidal side effects. which responses should the nurse document as indicating pseudoparkinsonism? a. rigidity b. tremors c. mydriasis d. photophobia e. bradykinesia (slow movement)

a. rigidity b. tremors e. bradykinesia

the nurse as a leader is teaching about Organizational Behavior Modification (OB Mod) theory of leadership to a group of student nurses. which statement made by the student nurse indicates effective learning? a. i should use punishment sparingly b. i should motivate staff by providing hierarchy of human needs c. i should use motivator factors liberally to inspire work performance d. i should assess each situation and determine action based on the people involved

a. i should use punishment sparingly

which statements by a nurse indicate that the nurse organization has no formalized mechanism for nurse input into organizational decision making? select all that apply a. i think my supervisor is not fit for that role b. what would they if i quit my job rn c. i can fill out an official complaint about my head nurse d. my organization is providing cultural competency care e. my organization also hires CNA

a. i think my supervisor is not fit for that role b. what would they if i quit my job rn c. i can fill out an official complaint about my head nurse

while caring for victims of a hurricane a nurse is teaching hygiene practices and symptoms of various infections. which phase of disaster management is the nurse executing? a. mitigation b. response c. evaluation d. preparedness

a. mitigation attempt to limit a disaster impact on human health and community functions

while caring for a client a nurse notes that the client has begun to create new words. what term does the nurse use to document this finding? a. neologism b. perseveration c. pressured speech d. tangential speech

a. neologism

a client newly diagnosed with scleroderma states, " where did i get this from?" how should the nurse reply a. the exact cause is unknown but it is thought to be a result of autoimmunity b. the exact cause is unknown but it is thought to be a result of ocular motility c. the exact cause is unknown but it is thought to be a result of increased amino acid metabolism d. the exact cause is unknown but it is thought to be result of defective sebaceous gland formation

a. the exact cause is unknown but it is thought to be a result of autoimmunity

when interacting a client says "as part of my religion i eat meat, fruits, grains, and herbs. we consider drinking cola, tea, and coffee unhealthy." which other practices may be related to the clients religion? a. wearing a clean and sacred undergarment b. celebrating open communion each sunday c. considering the bible to be the word of God d. seeking a blessing before going to the hospital e. notifying the funeral director to dress a dead body

a. wearing a clean and sacred undergarment d. seeking a blessing before going to the hospital e. notifying the funeral director to dress a dead body

one day after shaving a male client with diagnosis of bipolar disorder tells the nurse "i've hidden a razor blade and tonight i'm going to kill myself." what is the best reply by the nurse? a. you're going to kill yourself? b. things really cant be that bad c. are you sure you really mean that? d. killing yourself is not going to solve your problems

a. you're going to kill yourself?

a nurse is caring for a client with a history of hypertension and aphasia. a family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the clients aphasia. what is a common cause of this type of occlusion? a. history of hypertensive disease b. emboli associated with atrial fibrillation c. developmental defect of the arterial wall d. inappropriate paroxysmal neural discharge

b. emboli associated with atrial fibrillation

A nurse discusses the type of anesthesia that will be used for a vaginal birth with a client who has class I cardiac disease. Which type of block is most appropriate for this client? a. spinal b. epidural c. pudendal d. inhalation

b. epidural

Nurse is teaching a nursing student ways to reduce the risk for health disparities (differences) when communicating with a client who doesnt speak English. which statement made by the nursing student indicates a need for further teaching? a. i should communicate with the client without rushing b. i should use gestures to communicate with the client more effectively c. i should focus on translation rather than nonverbal communication d. i should do my best to interpret myself if the client doesnt understand English e. i should use simple terms instead of medical terminology to ensure understanding

b. i should use gestures to communicate with the client more effectively d. i should do my best to interpret myself if the client doesnt understand English

the RN is evaluating the statements of the nursing student about preferred provider organization (PPO's) which statement of the nursing student is correct? a. the goal of PPO is to keep the clients healthy b. the PPOs offer discount on fees in return for a large pool of potential clients c. the two national PPOs are kaiser permanente and united states family health plan d. the number of health care providers is more limited in PPO than in health maintenance organizations (HMOs)

b. the PPOs offer discount on fees in return for a large pool of potential clients

a female client with Hodgkin disease is to start total nodal irradiation. she and her partner who are planning a family become concerned when they learn that the radiation therapy includes the pelvic area. before responding what must the nurse consider? a. irradiation of the area will result in permanent sterilization b. the eggs in the ovaries can be removed and frozen for future use c. the radiation may be intense enough to cause sterilization of one ovary d. ovarian function will be destroyed temporarily but function will return after therapy

b. the eggs in the ovaries can be removed and frozen for future use

A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse? a. this drug will help you forget why you're lonely and depressed b. the medication will increase your appetite and make you feel better c. you'll start to feel much better after taking this medication for 2 to 3 days d. you'll feel less depressed when you take this with the monoamine oxidase inhibitor

b. the medication will increase your appetite and make you feel better

a client diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. while being admitted to ambulatory surgery by the nurse, the client has tears in her eyes and chin quivering. in a shaky voice client says, " I cant believe this is happening." what is the nurse best response? a. you cant believe this is happening? b. this must be a very scary time for you c. do you have any questions at this time? d. cancer of the breast has a high cure rate

b. this must be a very scary time for you

the nurse introduces himself/herself to the client while measuring the clients body temp. what is the reason for this intro? a. to gain the clients cooperation b. to decrease the clients anxiety c. to promote an efficiently completed procedure d. to ensure that the client is correctly receiving the procedure

b. to decrease the clients anxiety

After 4 days on the inpatient psychiatric unit a client on suicidal precautions tells the nurse, "Hey, look! I was feeling pretty depressed for a while, but I'm certainly not going to kill myself." What is the nurse's best response to this statement? a. you do seem like youre feeling better b. we should talk some more about this c. we have to observe you until youre better d. i dont understand what you mean by killing yourself

b. we should talk some more about this

a client who is pregnant for the first time and is carrying twins is scheduled for a c section. what should the nurse tell the client to expect? a. well give you an enema before the surgery b. well be encouraging you to walk early after surgery c. you'll be discharged from the hospital in a week d. you should take sponge baths until the incision is healed

b. well be encouraging you to walk early after surgery

a client who is delusional has refused to eat for the past 24 hours because he says "the food is poisoned." how should the nurse respond? a. why do you think that the food is poisoned b. you feel worried that someone wants to poison you? c. this feeling is a symptom of your illness its not real d. you'll be safe with me i wont let anyone poison you

b. you feel worried that someone wants to poison you?

A female client is scheduled for a hysterectomy. When discussing the preoperative preparation, the nurse identifies that the client has inadequate understanding of the surgery. What is the next nursing intervention? a. Describe the proposed surgery to the client b. Proceed with implementing the preoperative plan c. Notify the surgeon that the client needs more information d. Explain gently that she should have asked more questions

c. Notify the surgeon that the client needs more information

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client? a. Encouraging frequent naps b. Strengthening the concept of ageism c. Reinforcing the client's strengths and promoting reminiscing d. Teaching the client to increase calories and focusing on a high carbohydrate diet

c. Reinforcing the client's strengths and promoting reminiscing

LPN discusses the role of clinical nurse specialist in caring for a client with muscular dystrophy with a nursing student. which statement by the nursing student about the duties of the clinical nurse specialist is correct? a. a clinical nurse specialist counsels the client and family members b. a clinical nurse specialist assists in the examination and treatment of the client c. a clinical nurse specialist provides the clients care instructions to the caregivers d. a clinical nurse specialist assists in restoring the clients musculoskeletal functions

c. a clinical nurse specialist provides the clients care instructions to the caregivers

the nurse is assessing a client who reports frequent urination. which inquiry made by the nurse will help determine diabetes insipidus? a. do you have a history of cancer b. are you on fluroquinolone therapy c. are you on lithium carbonate therapy d. do you have history of lymphoma

c. are you on lithium carbonate therapy lithium carbonate known to interfere with normal kidney response to antidiuretic hormone

a client has a colostomy as a result of surgery for cancer of the colon. which nurses statement will most effectively minimize the clients stress for the first time self-irrigation is to be done? a. if you are still a little nervous because this is the first time, ill be happy to do it for you and you can do it next time b. you have to learn how to do this yourself before discharge. the best place to start is to assemble all the equipment needed for the irrigation c. ill draw the curtain and assemble all the equipment. would you like me to stay or do you prefer to try it yourself and call me if you need help d. you have a gown on so i wont draw the curtain unless you want me to do you feel comfy doing the irrigation or do you want me to do it instead

c. ill draw the curtain and assemble all the equipment. would you like me to stay or do you prefer to try it yourself and call me if you need help

One morning a female client with the diagnosis of schizophrenia tells the nurse that she is Joan of Arc and is going to be burned at the stake. What is the most therapeutic response by the nurse? a. tell me more about being Joan of Arc b. we both know you're not Joan of Arc c. it seems like the world is pretty scary place for you d. you're safe here because we wont let you be burned

c. it seems like the world is pretty scary place for you

a client with hemiplegia is staring blankly at the wall and reports feeling like half a person. what is the most appropriate initial nursing action? a. use techniques to distract the client b. include the client in decision making c. offer to spend more time with the client d. help the client to problem solve personal issues

c. offer to spend more time with the client

the HCP prescribes bathroom privileges only for a client with pulmonary edema. the client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. what is the nurses best reply? a. why do you want to be out of bed b. bed rest plays a role in most therapy c. rest helps your body direct energy to healing d. would you like me to ask your HCP to change the prescription

c. rest helps your body direct energy to healing

a nurse is counseling a client who has had an angry episode that subsided after several minutes. what is the most important short term objective for the client? a. continuing to vent angry feelings b. recognizing that way in which anger hurts others c. talking about situations that cause angry outbursts d. requesting increased medication when feelings of anger occur

c. talking about situations that cause angry outbursts

a client with borderline personality disorder receives the wrong meal tray for lunch and angrily states "the next time i see the dietitian im going to throw this tray at her" what is the most appropriate response by the nurse? a. suggesting that the client calm down and explaining that sometimes trays get mixed up b. informing the client that the behavior is inappropriate and sending the client out of the dining room c. telling the client that its frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior d. informing the client that throwing the tray at the dietitian will make matters worse and may result in his being placed in seclusion

c. telling the client that its frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior

a nurse is caring for a client who has undergone colostomy as a palliative treatment for advanced stage rectal cancer. a family member of the client asks the nurse whats the expected outcome of this surgery? which is the most appropriate response by the nurse? a. the clients problem or condition will be cured b. the clients malfunctioning organ will be replaced c. the client will experience relief or reduction of intensity of disease symptoms d. the clients lost or reduced body functions as a result of congenital anomalies will be restored

c. the client will experience relief or reduction of intensity of disease symptoms

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? a. nice job b. well done c. your performance was good d. you performed that procedure safely and professionally

d. You performed that procedure safely and professionally.

a nurse is teaching a male client about measures to maintains sexual health and prevent transmission of STD which statement of the client indicates effective learning? a. i will use condoms when having sex w infected partner b. i will perform a genital self examination every month before bathing c. i will refrain from getting the human papilloma virus vaccine before the age of 27 d. i will consult w my HCP when there is a rash or ulcer on my genitalia

d. i will consult w my HCP when there is a rash or ulcer on my genitalia

the RN is explaining basic rules for documentation to LPN which statements made by the LPN indicate effective learning? a. i will use generalized empty phrases b. i will fill the chart at the end of my shift c. i will leave few empty lines in the chart d. i will document the details when observed e. i will record in the chart using black ink pen

d. i will document the details when observed e. i will record in the chart using black ink pen

a nurse approaches a depressed client who is sitting alone in the day room. what is the best for the nurse to say to the client? a. may i sit w you for a while b. just call me if youd like to talk c. do you mind if sit and talk w you d. ill be sitting w you for a while today

d. ill be sitting w you for a while today

a client receiving steroid therapy states "I have difficulty controlling my temper which is so unlike me and i dont know why this is happening" what is nurse best response? a. tell the client its nothing to worry about b. talk with the client further to identify the specific cause of the problem c. instruct the client to attempt to avoid situations that cause irritation d. interview the client to determine whether other mood swings are being experienced

d. interview the client to determine whether other mood swings are being experienced

an adult is found to have schizotypal personality disorder (uncomfy with close relationships) how should a nurse describe the clients behavior? a. rigid and controlling b. submissive and immature c. arrogant and attention seeking d. introverted and emotionally withdrawn

d. introverted and emotionally withdrawn

a client who has been admitted with a diagnosis of schizophrenia says to the nurse "yes, its march. march is little women. that's literal you know." what do these statements illustrate? a. echolalia b. neologisms c. flight of ideas d. loosening of associations

d. loosening of associations

when a bedridden client complains that he/she is thirsty the nurse leader says "I want to make you comfy here is a glass of water please take it." which communication skill is the nurse leader using to make caring visible? a. listening actively b. expressing appreciation c. showing caring nonverbally d. making explicit her or his positive intent

d. making explicit her or his positive intent

the nurse notes that a client has been experiencing a somatic delusion. which statement led to this conclusion? a. I am jesus christ b. i know im dead c. this food has been poisioned d. my stomach has disintegrated

d. my stomach has disintegrated

a client with a diagnosis of antisocial personality disorder is being discharged from the hospital. the client asks the nurse, "can i have your phone number so i can call you for a date?" what is the best response by the nurse? a. we are not permitted to date clients b. it is against my professional ethics to date clients c. im glad you like me but i cant give out my phone number d. our relationship is professional therefore i will not see you socially

d. our relationship is professional therefore i will not see you socially

a client who recently gave birth is transferred to the postpartum unit by the nurse. what must the nurse do first to avoid a charge of abandonment? a. assess the clients condition b. document the clients condition and the transfer c. orient the client to the room and explain unit routines d. report the clients condition to the responsible staff member

d. report the clients condition to the responsible staff member

a LPN discusses hospice care with a nursing student. which statements made by the nursing student indicates a need for further discussion? Select all that apply a. a clients spouse is considered a primary caregiver b. the hospice Medicare benefit covers all expenses for palliative treatments c. a hospice provides dying older adults with a higher level of control and dignity in death d. the hospice medicare benefit for bereavement care isnt provided after the death of the client e. hospice care can be provided to all older adults requiring hospitalization for the treatment of an illness

d. the hospice medicare benefit for bereavement care isnt provided after the death of the client e. hospice care can be provided to all older adults requiring hospitalization for the treatment of an illness

when a nurse accompanies a mother to the NICU to see her preterm infant for the first time the mother starts to cry and will not touch the infant. how should the nurse interpret the mothers response? a. incomplete attachment b. rxn to the environment c. expected detachment behavior d. typical rxn to the situation

d. typical rxn to the situation

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. The nurse expects the client to describe the chest pain as:

severe, intense