409 RQ 4

10. The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would implement neutropenic precautions if the client's white blood cell count was which value?

1. 2,000mm3 Normal WBC count 5000-10000.

6. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would the nurse report before administering the dose of furosemide?

1. 3.2 mEq/L normal serum potassium 3.5-5.

7. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply.

1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 4. Segmented neutrophils 40% (0.40) 6. White blood cells, 3000 mm3 (3.0 × 109/L)

12. Which interventions are appropriate for the care of an infant? Select all that apply.

1. Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes.

11. The parent of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse would tell the parent that the most appropriate toy for a 3-year-old is which?

1. a wagon

A client is unwilling to go to church because the ex-spouse goes there and the client feels that the ex-spouse will laugh at the client. Because of this hypersensitivity to a reaction from the spouse, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?

1. avoidant

4. A hospitalized client with a history of alcohol use disorder tells the nurse: "I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take?

1. call the nursing supervisor patients are allowed to leave against medical advice.

9. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

1. communicate expected behaviors to the client. 3. assist the client in identifying ways of setting limits on personal behaviors. 4. follow through about the consequences of behavior in a nonpunitive manner 6. have the client state the consequences for behaving in ways that are viewed as unacceptable.

11. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take?

1. contact the nursing supervisor

5. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply.

1. dental decay. 3. loss of tooth enamel. 4. electrolyte imbalances.

1. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child's fears?

1. encourage the child's parents to stay with the child makes separation difficult from the parents

3. The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement?

1. i no longer feel that i deserve the beatings my partner inflicts on me.

12. The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information would be included in the discharge instructions?

1. information regarding shelters.

2. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

1. monitor vital signs. 2. provide a safe environment. 3. address hallucinations therapeutically. 5. provide reality orientation as appropriate.

11. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention would the nurse include in the plan of care?

1. one-to-one suicide precautions required for someone with attempted suicide.

10. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

1. provide a safety for the client and other clients on the unit.

3. The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next?

1. reassess the client. reassess frequently because complications do not always appear after the fall

6. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention would the nurse initially implement?

1. setting limits on the clients behavior.

11. A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level?

1. toxic maintenance levels are 0.6-1.2. toxic level is 1.5.

8. The nurse is assessing a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to notify the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply.

1. warfarin 2. Glimepiride 3. Amlodipine

7. A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?

1. we will be sure not to leave hot liquids unattended.

8. Which notations indicate accurate nursing documentation by the nurse? Select all that apply.

1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

3. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

2. 15 mg/dl normal BUN is 10-20.

9. The parent of a 3-year-old is concerned because the child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the parent?

2. Allow the bottle if it contains water.

6. The nurse is teaching a client who is being started on imipramine about the medication. The nurse would inform the client to expect maximum desired effects at which time period following initiation of the medication?

2. In 2 to 3 weeks

17. The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system.

7. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?

2. a client undergoing diagnostic tests.

7. The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.

2. acknowledge the clients behavior. 3. assist the client to an area that is quiet. 4. maintain a safe distance from the client.

1. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care?

2. ask the client about the amount of drug use and its effect

9. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action?

2. assess and treat the wound sites.

1. A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how would the nurse administer the dose?

2. at the same time each evening.

12. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first?

2. attempt to arouse the client respiratory depression and hypotension are main concerns for opiate OD.

13. The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include?

2. avoid using a whisper voice in front of the client. whispering would make the client not trust you .

3. Which car safety device should be used for a child who is 8 years old and 4 feet tall?

2. booster seat

4. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action?

2. clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.

5. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

2. document the finding this is normal

4. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?

2. document the findings normal respiratory rate: 20-40

10. A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior?

2. evidence of the clients disturbed body image.

9. The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding specific side and adverse effects of the medication?

2. gastrointestinal dysfunctions

1. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

2. holding the next dose of warfarin normal PT is11-12.5 seconds.

15. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

2. i keep reliving the robbery. 3. i see that face everywhere i go 5. i might have died over a few dollars in my pocket.

4. When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?

2. identifying anxiety producing situations.

4. The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information would the nurse incorporate in the discussion?

2. increase fluids and bulk in the diet causes constipation, so increase fluids and bulk.

10. A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?

2. rapid heartbeat or anxiety

5. The nurse in the emergency department is caring for a young victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How would the nurse interpret these behaviors?

2. reactions to a devastating event.

13. A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication?

2. seizure activity. occurs when taking more than 450mg daily.

4. The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

2. taking oral temperature for a client with a cough and nasal congestion

8. The nurse notes that a client with schizophrenia who is receiving an antipsychotic medication is moving the mouth, protruding the tongue, and grimacing while watching television. The nurse determines that the client is experiencing which medication complication?

2. tardive dyskinesia

8. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

2. the adolescent gives away a DVD and a cherished autographed picture of a performer. they give something away of value as a way of saying goodbye and wanting to be remembered.

2. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

2. the death of a loved one situation crisis is external, not internal.

2. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially?

2. use an indirect light source and turn off the television. noise may add to confusion.

6. The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?

2. uses a cup to drink

9. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse?

2. what do you find difficult about this situation?

14. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?

2. writing. solitary activities that require short attention span with mild physical exertion are appropriate for a client with aggressive behaviors.

7. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which action(s) to correct the error in the MAR? Select all that apply.

2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information.

12. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

3. Call the nursing supervisor and report the occurrence.

13. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

14. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

3. assigning to the client a staff member who will remain with the client at all times.

5. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

3. call the nursing supervisor.

14. A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly?

3. client arrives at the clinic neat and appropriate in appearance.

7. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?

3. conversion disorder. conversion disorder is the alteration or loss of a physical function that cannot be explained by any known cause.

7. A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse would instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply.

3. crackers. 5. tossed salad. avoid foods high in tyramine, due to causing HYPERtensive crisis.

1. A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?

3. do you feel afraid that people are trying to hurt you

8. A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement?

3. escort the client to their room, with the assistance of other staff.

2. A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

3. i will be sure to cue in to any indicators that the client may be exaggerating pain dont assume a patient is exaggerating pain.

10. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention would the nurse include in the plan?

3. increasing the level of suicide precautions unlikely to have such a dramatic cure. a lift in depression, they have made the decision to harm themselves.

13. A client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

3. iron deficiency anemia. Normal hemoglobin 12-18. (120-180)

12. The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?

3. sit beside the client in silence with simple open-ended questions

13. A victim of a sexual assault is being seen in the crisis center. The client states, "I still feel as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?

3. tell me more about the incident that causes you to feel as if the rape just occurred.

1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report?

3. the client was found lying on the floor.

2. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

3. transport the victim to the operating room for surgery. do not need consent when an emergency is present and delaying treatment results in injury or death.

3. The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?

3. what leads you to seek help now

11. The nurse is preparing a client with schizophrenia and a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?

3. when i have command hallucinations, ill call a friend for help. call a nurse or counselor, not a friend.

1. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?

3. you seem restless; tell me what is happening.

6. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?

4. "You sound very upset. Are you thinking of hurting yourself?"

4. The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse would consider which factor?

4. A client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client.

15. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse would ask the child and parent about a history of a severe allergy to which substance?

4. A previous dose of hepatitis B vaccine or component

14. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention would the nurse suggest to the parent?

4. Apply a cold pack to the injection site.

16. A parent brings a 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant?

4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

11. A client with a history of atrial fibrillation brought to the emergency department has accidentally been taking two times the prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

4. Draw a sample for prothrombin time and international normalized ratio plan to draw a sample for PT and INR to determine the clients anticoagulation status and risk for bleeding.

8. A parent arrives at a clinic with a toddler and tells the nurse how difficult it is to get the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the parent?

4. Inform the child of bedtime a few minutes before it is time for bed.

14. A client with peptic ulcer disease and a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would plan to take which action after seeing the laboratory results?

4. Place the normal report in the client's medical record. normal platelet 150,000-400,000.

3. A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention?

4. a structured program of activities in which the client can participate.

2. A 16-year-old client is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

4. allow the client to interact with others in their same age group. peer group will support client

10. An older client is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. The nurse plans to make which most appropriate response?

4. as a nurse, i am legally bound to report abuse. i will stay with you while you give the report and help find a safe place for you to stay.

3. A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety?

4. avoid drinking alcohol while taking this medication this is an anticonvulsant and hypnotic agents. avoid any other CNS depressants.

10. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?

4. crayons and a coloring book

12. A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?

4. frequent handwashing with hot, soapy water. used to treat OCD, if stop taking it it causes them to come back.

5. The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction would the nurse provide to the client?

4. get up slowly when changing positions.

8. The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?

4. hypertension, changes in level of consciousness, hallucinations.

6. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client?

4. i will call the nursing supervisor to seek assistance regarding your request.

6. The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?

4. interrupt the client and offer to take the client for a walk. stops harmful behavior, but provides the client with a activity to decrease anxiety

5. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

4. leaving the rate of heparin infusion as is. therapeutic dose for treatment of DVT is aPPT between 1.5-2.5 times normal (45-60, 75-100)

9. A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

4. observing care provided to the client without the clients permission.

9. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

4. preventing and recognizing hyperglycemia. a1C normal is less than 7.5.

2. A client with schizophrenia has been started on medication therapy with clozapine. The nurse would assess the results of which laboratory study to monitor for adverse effects from this medication?

4. white blood cell count agranulocytosis is an adverse effect that could be fatal if untreated.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care, anticipating which client behavior?

a willingness to participate in the planning of care and treatment plan.

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would plan to tell the client that which is the first step in this 12-step program?

admitting to having a problem

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.

battery, assault, false imprisonment.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially?

contact the clients primary health care provider.

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?

helping the client to examine dysfunctional thoughts and beliefs.

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

i cannot discuss any client situation with you

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action would the nurse plan to engage in during the working phase of the nurse-client relationship?

inquiring about examining the clients feelings for any that may block adaptive coping

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

it sounds as if you are feeling angry that your family continues to hope for you to be cured restating is a therapeutic communication. shows understanding.

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which therapeutic response would the nurse make?

it sounds as if youve been feeling like a failure for a while.

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?

milieu therapy

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse would provide which intervention for this client?

monitor closely for harm to self or others.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.

restating, active listening, maintaining neutral responses, providing acknowledgement and feedback.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which therapeutic response would the nurse make?

tell me more about your sleep over the past few nights exploring therapeutic technique

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

tell the client to stop monopolizing in a firm but compassionate manner

The nurse would plan which goals for the termination stage of group development? Select all that apply.

the group evaluates the experience. the group explores members feelings about the group and impending separation.

A client experiencing disturbed thought processes believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat?

using open-ended questions and silence. encourage clients to discuss their problems