211- Exam 1

Which of the following statements would be an empathetic response in a client interaction?

"You must have been embarrassed when your father yelled at you in the grocery store."

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response.

-"I am obligated to share that information with the treatment team."

A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?

-"I check where my car keys are eight times."

Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention?

-"I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." -Rationale: This might indicate suicidal ideation

A school age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response

-"Tell me more about how you feel

The nurse is trying to obtain some information about family relationships from the client. Which of the following statements is best?

-"Tell me your feelings about your family situation.

A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism?

-"That person should not have provoked me."

The nurse is preparing to give a group therapy session for clients with posttraumatic stress disorder (PTSD). Which clients are most likely to be included in the group therapy session? Select all that apply.

-A client who is a victim of a car accident. -A client who has lost his wife and children in a natural disaster. - A client who has witnessed a murder.

When a psychiatrist prescribes alprazolam for acute anxiety experienced by a client with agoraphobia, health teaching should include which instructions?

-Avoid alcohol

Which parental characteristics is least likely to be a risk factor for child abuse

-Being a member of a large family

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child?

-Chronic low self-esteem related to negative feedback from parents

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

-Depression

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?

-Do you find it difficult to control your worrying?"

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely?

-Emotional

A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually abused repeatedly by her husband. Which of the following interventions would be appropriate in relation to this piece of data?

-Encourage her to talk about her feeling related to the abuse

A nurse is developing a therapeutic relationship with the client. To do this, the nurse must respect the client's religious and spiritual beliefs. Which of the following will occur if the nurse does not show this respect

-Eroding trust

Which of the following is the best explanation for why family violence tends to occur over multiple generations of families?

-Family violence may be perpetuated between generations of families by role modeling and social learning.

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described?

-Flashback

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving?

-Honeymoon -Rationale: The honeymoon phase is when the abuser will apologize and offer gifts

A 40-year-old client who is quite anxious says that she would "rather die than be pregnant." Which of the following responses by the nurse is most helpful?

-I see you're upset. Take some deep breaths to relax a little."

A young woman telephones the emergency department and loudly tells the nurse, ìI've been raped! Please help me!î Which of the following is the priority for the nurse to determine?

-If the client was in a safe place, her condition, and if transportation is available -Rationale: Safety is the number one priority, options about insurance and assailant identity are not priority at the moment. The option about if the patient has bathed is important but not priority over her safety.

The client is talking to the nurse about her intimate relationships. Which one of the following statements regarding intimate partner violence is true?

-Intimate partner violence can exist with former partners. Rationale: The other responses are incorrect facts about intimate partner violence

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic?

-Lorazepam

A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?

-Lower the patient's current anxiety.

A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?

-Persistent thoughts about bacteria, germs and dirt

An elderly client with dementia lives with her daughter. During the day the client attends a Day Center. The nurse notices the client is unkempt and smells of urine. Upon examining the client, the nurse notes bruising on her arms and back. From the nurse's observations, which of the following is the type of abuse suspected?

-Physical abuse -Rationale: The nurse's assessment (bruising, smells of urine, client is unkept) shows correlation with physical abuse. The other options do not correlate with the nurse's assessment

A nurse is working with a patient experience panic level anxiety, which nursing intervention should be implemented first

-Provide calm, brief, directive communication

A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing an effort to obtain which of the following?

-Relieve from anxiety

The nurse is admitting a child with a history of abuse. The nurse understands that the child may show what behaviors that are consequences of being in an abusive environment? (select all that apply)

-Reliving abuse incidents -Sleep disturbance -Acting out behaviors

What is a nurse's legal responsibility if child abuse or neglect is suspected?

-Report the suspected abuse or neglect according to state regulations -Rationale: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

The nurse in the mental health unit reviews therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply.

-Restating -Listening -Maintaining neutral responses -Providing acknowledgment and feedback

The nurse is working on a behavioral health unit. A patient fearfully runs from chair to chair crying, "they're coming! They're coming!" The patient does not follow the staffs directions or respond to verbal interventions. The highest priority diagnosis is

-Risk for injury -Rationale: The patient's safety is priority over the other diagnosis.

The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands, and trembling. His speech is high pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his anxiety level as

-Severe

A young female immigrant presents in the rural health clinic with facial bruising and a fractured nose. The client is reluctant to give details of the nature of her injuries. Which of the following should be a consideration in providing care for this client?

-She may fear deportation if she seeks public assistance.

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma related disorder?

-Take advantage of offered counseling

A crisis intervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population?

-The abused person may return to the abusive home setting. -Rationale: This is a common problem within the domestics violences victims

Which of the following are typical characteristics of the perpetrator of intimate partner abuse? Select all that apply.

-The perpetrator often believes that the partner is his own property. -The perpetrator is often irrationally jealous, even of his own children if the partner pays any attention to them. -The perpetrator is emotionally immature and needy.

A client states, "I feel fine. It's a good day." The nurse notes the client looking away, and a decreasing pitch in his voice while speaking. Which of the following is the most therapeutic response by the nurse?

-You say you feel fine, but you don't really sound fine."