Quiz 1

A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make?

"Are you feeling helpless about changing this behavior?" - The nurse should use the therapeutic communication technique of restating when responding to the feelings the client has expressed. Restating focuses on the main idea of the client's statement and helps the client understand and explore personal behaviors.

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory?

"What year did you graduate from high school, Billy Jean?" *Ask a question that can be validated

A nurse in an emergency department is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse?

"My child was riding their bicycle, and fell off" - The nurse should suspect possible child abuse in response to this statement because an 18-month-old toddler is not expected to have the developmental ability to ride a bicycle.

A nurse in a mental health clinic is caring for a client who has bipolar disorder and states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication?

"You feel better when you dont take your medication?" *Validating or clarifying the client's feelings. The client has stated a preference for not taking the medication. This open-ended paraphrasing acknowledges the client's statement and allows for further exploration of the subject.

A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse make?

"You must be very upset about something, Jaquan, if you want to see the provider in the middle of the night"

A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make?

"The next time this occurs, what might you do to ensure your safety?" - The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future.

A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make?

"You must feel very frightened, if you think someone wants to hurt you"

A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an OVERT statement indicating the client's risk for suicide?

"There is no point in living any longer" - The nurse should identify this client comment as an overt statement about the client's risk for suicide. The nurse should assess the client's suicidal ideation further and implement interventions to promote her safety. - The other options are covert statements.

A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal. The client reports hand tremors 12 hr after admission. Which of the following statements should the nurse make?

"These tremors will persist for the next few days as you are withdrawing from alcohol" - The nurse should inform the client that tremors, as well as other manifestations of alcohol withdrawal, might persist for several days after the last intake of alcohol.

A nurse is counseling a client who seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make?

"What were we discussing that begin to make you feel uncomfortable, Craig?"

A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse as his favorite stating, "He's the best nurse ever." When that nurse calls in sick, which of the following statements indicates that the client is using splitting as a method of coping?

"He is the worst nurse that has ever taken care of me" - The nurse should identify that the client is using splitting when he relates to others as if they are all good or all bad, rather than as integrated individuals who have both positive and negative attributes. Clients who have borderline personality disorder might use this coping style as a defense mechanism.

A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I should keep client info private even after the client, Harold, dies"

A nurse enters a client's room, and observes that the client is agitated and pacing rapidly. The pt looks at the nurse and says, "back off. Leave me alone" What statement should the nurse make?

"I will give you some space if you calm down. Tell me what is making you feel so tense." *Stay at safe distance and remain calm

A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic?

"I would like to sit and talk to you" *Offer oneself to demonstrate caring and interest in the client and the client's feelings.

A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make?

"In other words, you seem to be saying you feel unworthy of help" - The nurse should use the therapeutic technique of paraphrasing to clarify the client's statement and promote further communication.

A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make?

"You sound upset, bridget, are you thinking of hurting yourself?" - Focus on the clients feelings!!! - This response exemplifies the therapeutic communication technique of showing empathy. Telling the client, "You sound upset," focuses on the client's feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the client directly whether or not she has an intent to harm herself.

A nurse is preparing to administer fluphenazine decanoate 12.5 mg subcutaneous. Available is fluphenazine decanoate 25 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

(12.5mg/25mg) x 1 mL = 0.5 mL

A nurse in a pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients?

A 9-month old who nearly drown by having accidentally fallen into the tub and turned the water on. - he nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9-month-old infants.

A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of the following actions should the nurse take first?

Ask the client to complete a CAGE questionnaire - Begin was assessment/data collection. - The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client's alcohol use. Use of a CAGE Questionnaire is helpful to determine the impact of alcohol use on the client's life.

A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority? A. "I hate being so helpless. I can't even manage my own finances anymore." B. "At group therapy today I wanted to leave. I didn't feeling like being with other people." C. "I have it all figured out. Everything is going to be okay now." D. "I don't feel like showering. I'd rather just stay in bed today."

C - The nurse should identify that this client statement is the priority because it indicates a possible plan for suicide. This reaction is possible after starting an antidepressant when the client gains the energy to act upon suicidal thoughts.

The nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors?

Countertransference *The nurse unconsciously attributing feelings, positive or negative, about another toward a client

A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, "Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms?

Denial

A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first?

Denial *followed by anger, bargaining, depression, acceptance

A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room and the client begins yelling, "I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms?

Displacement *Redirection of thoughts, feelings, impulses, from an object that causes anxiety to a safer more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care.

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take?

Document the clients behaviors every 15 minutes while in restraints *There should be TWO fingers that can fit between wrist and clients restraint *There should be someone one-on-one with the client at all times while in restraints - This frequent documentation meets the legal requirement for use of restraints; helps provide for prompt identification of complications related to restraint use; and helps ensure that restraints are removed as soon as possible, depending on the client's behavior.

A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse take?

Document the clients refusal in the medical record

A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take?

Explain that the time is designated to be focused on the client - The nurse should understand the difference between a therapeutic nurse-client relationship and a social relationship. The nurse should explain to the client that the counseling session time is designated to focus on the client and resolution of his problems.

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?

Expressed feelings of decreased self worth - The nurse should expect the client who has anorexia nervosa to have an altered sense of self-image and self-identity. The client often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the client views herself as overweight.

A nurse is caring for a client who has borderline personality disorder. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. After providing first aid, which of the following actions should the nurse take first?

Identify the clients feelings that lead to the self injury *Nursing process - collecting data is first - The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assist the client to identify events or feelings that led to his self-injurious behavior.

A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase?

Identify the clients perception of the reason for therapy - In the initial, orientation phase of the nurse-client relationship, the nurse should establish rapport and confidentiality with the client. The nurse should assess the client's beliefs about the reason for therapy.

A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions?

Place the client on one-on-one observation - The nurse has both a legal and professional responsibility to provide a safe environment for the client who is at risk for suicide. The client who is at high risk for suicidal behavior requires constant one-to-one observation to ensure safety.

A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms?

Projection - The nurse should identify that a client is using projection when unconsciously transferring unacceptable feelings, thoughts, or traits in oneself onto another person. This response is maladaptive because it prevents the client from accepting responsibility for personal performance in school.

A community mental health nurse is planning strategies to address substance use by adolescents. Which of the following interventions should the nurse plan as a method of primary prevention?

Provide a presentation at area high schools on resisting peer pressure for substance abuse - Planning interventions that prevent the onset of substance use is an example of primary prevention. By providing information to adolescents on methods to resist peer pressure for substance use, the nurse can help prevent the substance use from occurring.

A nurse is caring for a school-age client who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should identify that the client is exhibiting which of the following defense mechanisms?

Regression - The nurse should identify that regression represents a dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the client better tolerate the anxiety.

A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions?

Somatic *Believe that their body part in no longer functioning in a realistic or expected manner

A nurse is caring for a client whose adolescent child died in a motor-vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take?

Stay with the client and allow the client to cry *Offer self *Silence is a therapeutic technique for those who are grieving

A nurse is planning care for a client who has thoughts of suicide. Which of the following goals should the nurse include in the client's plan of care?

The client agrees to notify a staff member of thoughts of self harm - The nurse should instruct the client to notify staff if he has suicidal thoughts so that the client's needs are immediately addressed and actions are taken to prevent self-injury or suicide.

A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as the priority?

The client gives his favorite possessions to his friends - Giving away valued and prized possessions is an indication of suicidal ideation, which is the greatest risk for clients who have depression. - The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify this finding as the priority.

A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect?

The client has difficult concentrating (also focusing) - The nurse should expect the client who has moderate-level anxiety to have difficulty concentrating and focusing. This lack of concentration increases as the anxiety level escalates.

A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy?

The client will gain increased self-esteem