Qbank test 2

The nurse provides care for a client diagnosed with substance abuse. The nurse recognized the client is using projection as a defense mechanism when the client makes which statement?

"My spouse takes handfuls of medications, and I dont do that"

A client diagnosed with bulimia nervosa discusses how to identify abnormal eating behaviors with the nurse. Which statement, if made by the client to the nurse, indicates the client is beginning to understand the behaviors associated with the diagnosis?

"when I am sad or stressed, I binge eat to make myself feel better, but I know it is not really solving anything." "I throw up after eating a lot and, if i do not change my ways, my body will suffer from complications

A clients younger adult child is at the bedside and expresses a desire to be the medical power of attorney. The older adult child shows up at the bedside and states a desire to be the medical power of attorney as well. The client is competent, alert, and oriented. How will barriers and stressors that affect family functioning be assessed?

1. The nurse asks all visitors to leave the room in order to speak with the client privately 2. the nurse asks the clients preference for which adult child should act as the MPOA 3. The nurse verifies the clients decision in choosing the MPOA 4. The nurse requests permission to be the mediator when the client informs the adult children of the choice 5. the nurse brings the adult children back into the room to discuss the clients decision 6. the nurse offers support and chaplain resources to the adult children after the decision has been discussed

The nurse provides care for a client before and after electroconvulsive therapy. In which order does the nurse complete the associated nursing interventions?

1. explain the procedure to the client 2. ask the client to void 3. administer atropine about 30 minutes before treatment 4. orient the client after the procedure

The home health nurse develops a care plan for a client diagnosed with Alzheimer disease. What process will the nurse teach the family to follow in order to safely administer medications to the client at home?

1. turn off the television 2. allow the client to choose between water or apple juice 3. give medication instructions in simple, clear steps 4. allow the client to hold the medicine cup and take medications when ready

The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn?

A client who woke up from a nap recently, just ate a snack, and is sitting up in bed

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first?

A police officer with a history of PTSD and who was admitted with agoraphobia after two of his co-officers were killed

The psychiatric home health nurse is planning client visits for the day. Which client does the nurse see first?

An adult client diagnosed with schizophrenia and who hears voices directing harm to others

The nurse counsels the spouse of a client diagnosed with generalized anxiety disorder about how to cope with the clients anxiety. Which statement made by the spouse indicates that teaching is successful?

Anxiety represents an unconscious conflict of needs

The health care provider documents in a clients medical record the statement "bizarre gesturing, decline in hygiene, and command hallucinations" which action is most important for the nurse to take when caring for this client?

Ask the client what the voices are saying.

The nurse notes that a toddle client has numerous bruises, a possible fractured left numerus, and several lacerations. Which action will the nurse take first?

Ask the parents what caused the injuries

A client diagnosed with pancreatic cancer says to the nurse, "Why is this happening to me? It feels like God is punishing me." Which intervention represents appropriate nursing care for this client?

Be physically present listen actively and seek clarification use gentle touch and comfort and show concern provide protected privacy and quiet time

The nurse receives a call from a client who is 2 weeks postpartum. The client reports feeling irritable, anxious, fatigued, and tearful, as well as having unpleasant thoughts. Which questions is most important for the nurse to ask?

Do you ever think about harming yourself or the baby?

The nurse provides care for a client with a history of substance abuse. Which intervention does the nurse include in the plan of care for this client?

Encourage the client to participate in AA meetings with a sponsor

The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, "I am having trouble sitting still. Am i bothering anybody? Maybe I should not come to these meetings." Which action by the nurse is best?

Encourage the client to share problems with the group

While the nurse provides end of life care to a terminally ill client, the client suddenly becomes tearful and states, "I regret not traveling more when I was healthy." Which action by the nurse is most appropriate?

Encourage the family to show the client pictures of places the client has traveled

An older adult client diagnosed with early stage dementia frequently paces the halls and becomes physically exhausted. To reduce the clients pacing which intervention should the nurse implement?

Have the client complete a simple, monotonous activity

The nurse provides care for clients on the psychiatric unit. The nurse identifies which comment by a client as indicative of a dissociative disorder?

I do not know who I am or where I live

During a routine physical examination, the nurse notes that the clients spouse died 2 months ago of colon caner. Which initial statement is best for the nurse to make to this client?

I understand that your spouse died two months ago

A client undergoes admission to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one to one observation of the client?

I will not sign a no suicide contract

The nurse prepares a client for a left total hip replacement. Which statement by the client indicates to the nurse that the client exhibits an emotional readiness for surgery?

Im glad the trapeze is here so I can start working on my exercises as soon as I wake up.

A client newly diagnosed with a terminal illness states, I cannot believe this is happening. How am I going to get through this? which response by the nurse will assess the presence of a support system for this client?

Is there someone we can call to drive you home? DO you attend a church or are you a member of any spiritual group? Are you aware that you can contact a group for people who have the same diagnosis as yours? Are there family members or friends you often talk to? Do you live with anyone at home?

A client diagnosed with depression states, "my boss is angry at me for not doing my job as well as I used to." Which is the best response by the nurse?

It must be hard to keep up with work when you're feeling depressed

The parents of a newborn client diagnosed with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which statement is best for the nurse to make to the parents at this time?

Let me show you pictures of some babies before and after surgery

The nurse plans care for a client diagnosed with anorexia nervosa. Which goal will the nurse make a priority for this client?

Maintain potassium balance between 3.5 and 5 mEq/l

The nurse provides care for a client diagnosed with bulimia nervosa. Which intervention does the nurse initiate as part of the clients plan of care?

Monitor the client for an hour after meals assist the client in identifying situations that produce anxiety provide a quiet, non-stimulating environment for the client weigh the client every morning on the same scale establish the treatment plan with the client

The nurse is talking with a client who is a successful write. The client reports recently experiencing epigastric pain and palpations prior to a book signing. Which client statement requires an intervention by the nurse?

No matter how much I prepare for book launches, I still get anxious and nauseous

The nurse provides home care for an older adult client diagnosed with impaired hearing. Which action is best for the nurse to implement based on this data?

Obtaining an amplified telephone for the client

A nurse enters the room of a client who is scheduled for surgery. The client is pacing the room with hands balled into fists. Which response by the nurse is appropriate?

Please tell me what you are thinking about How have you handled previous stressful situations in your life?

The nurse provides care for clients diagnosed with eating disorders. The nurse understands that it is most important to assess for which problem?

Poor self identity and poor self esteem

Which action does the nurse take to utilize milieu therapy when providing care to clients in a psychiatric inpatient setting?

Provide a consistent set of activities and responsibilities for each client

The nurse provides care for a client in the ED and who is shaking and crying after witnessing a fiend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the clients plan of care?

Remain with the client administer prescribed lorazepam 1mg orally provide privacy for the client write down important information

The nurse provides care for a client scheduled for ECT. The nurse observes that the client is anxious. Which action by the nurse is best?

Remain with the client to discuss fears

The nurse interacts with a client who has just accepted a job in an office located on the 36th floor of a building. The client reports experiencing severe anxiety in elevators and enclosed spaces. Which intervention is most important for the nurse to recommend?

Systematic desensitization

A client in a substance abuse treatment facility says to the nurse, "my life cannot get any worse. I have to stop drinking before it is too late." Which response by the nurse is most appropriate?

Tell me how drinking has affected your daily life.

The home health nurse visits a client diagnosed with dementia. The client lives with an adult child and family. The nurse identifies which stressor as most critical to the family?

The client does not recognize family members

The nurse provides care for a client taking fluoxetine for 2 weeks. Which observation most concerns the nurse?

The client has been giving away some possessions

The nurse provides care to a client scheduled to undergo a craniotomy the following day. Which client information does the nurse recognize as being an indication for insertion of an indwelling urinary catheter?

The client is diagnosed with severe urinary retention The client is scheduled for a lengthy surgical procedure the client requires strict monitoring of intake and output

The nurse admits a client diagnosed with bipolar disorder. Which assessment requires immediate attention by the nurse?

The client refusing to eat breakfast, lunch, or dinner

An adult client admitted to the inpatient psychiatric unit is diagnosed with dissociative identity disorder DID. Which occurrence indicates to the nurse that the client is improving?

The client turns and looks when called by a staff member

A client is terminally ill and days away from death. The hospice nurse wants to help the client cope by discussing end of life needs. Which topic is appropriate to discuss at the end of life?

The effects of dehydration the possibility of hallucinations fears of the unknown

A client with a history of alcohol abuse tells the nurse " I am not an alcoholic. I am only a social drinker." Which response will help the client acknowledge the alcohol abuse?

The record says you've been arrested for drunk driving three times in the past year what problems are associated with alcohol use in your life?

The nurse provides care for a client experiencing alcohol withdrawal delirium. The client tells the nurse that bugs are crawling on the walls in the room. Which action by the nurse is appropriate?

Turn the lights on and remain with the client.

The nurse provides information about acute grief reaction to volunteers of a mobile disaster unit. Which statement made by a volunteer indicates to the nurse the need to provide further teaching?

We should not allow a survivor to assist us in our duties

The nurse provides care to a client who is experiencing a manic episode of bipolar disorder. Which statement by the client is most expected during a manic episode?

When I am discharged, I will be starting my own company.

The nurse provides care for a client admitted for abdominal surgery. During the admission interview, the client admits to drinking 1 pint of vodka per day. Which is the best initial response by the nurse?

When did you have your last drink of alcohol?

When assessing a client admitted to rule out a MI, the nurse determines a history of alcoholism. Which question is a priority for the nurse to ask the client?

When did you have your last drink?

A nurse provides care for a client who was admitted to the mental health unit following a suicide attempt. When talking to the sibling of the client, which question is appropriate for assessing the family dynamics?

Who would you describe as the leader of the family? What would you describe as a strength of the family? WHat is something you think should change in your family?

The nurse provides care for four clients. Which client does the nurse recognize is at risk for experiencing sensory overload?

an older adult client admitted for emergency surgery

The nurse assesses a client in the ED. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack

decreased perceptual field, diaphoresis, fear of going crazy, and palpations