Exam 2 ATI
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reacitons? A) Denial B) Displacement C) Projeciton D) Undoing
A) Denial
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? A) Hypotension B) Viral infection C) Increased energy D) Increased cognitive awareness
B) Viral infection
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect? A) Tachycardia B) Constipation C) Metrorrhagia D) Hyperkalemia
B) Constipation
A nurse is assessing the medical record of a female client who has anorexia nervosa. Which of the following findings should the nurse expect? A) Decreased cholesterol levels B) Low bone density C) Heavy monthly periods D) Heat intolerance
B) Low bone density
A nurse is providing teaching to a client about smoking cessation. Which of the following client statements indicates a need for further education? A) "I will test my ability to quit smoking by going to the bar where I used to smoke." B) "I will distract myself by working on my woodworking hobby." C) "I will call someone I know who has quit if I develop the urge to have a cigarette." D) "I will keep a journal to understand what is triggering the urge to smoke."
A) "I will test my ability to quit smoking by going to the bar where I used to smoke."
A nurse is providing care for a client who seems anxious following a recent tragedy. Which of the following statements by the client reflects an adaptive use of sublimation? A) "I will work out in the gym every time I get mad about what happened." B) "I do not have anxiety, and I'm not sure why not you think I do." C) "I can't remember anything that happened, but I am okay." D) "I'm not capable of moving past this time in my life."
A) "I will work out in the gym every time I get mad about what happened."
AA mental health nurse is referring a client who has an alcohol addiction to a 12-step Alcoholics Anonymous program. The nurse should inform the client that which of the following is the basic concept of a 12-step program? A) Admit life is unmanageable. B) Detoxifying from the addictive substance. C) Identifying stimuli that promote drinking. D) Including family in counseling sessions.
A) Admit life is unmanageable.
During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression? A) "I wrote a short story about a heroic woman when I was really mad at my boss." B) "I don't care about work anymore since I was not given a promotion." C) "I mentally separate myself from distractions around me when I paint on canvas." D) "I still cannot remember the scene of my husband's car accident."
B) "I don't care about work anymore since I was not given a promotion."
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? A) Sleeping 12 hr or more each day. B) Increasing sense of attachment to others. C) Constant need to talk about the event. D) Increasing feelings of anger.
D) Increasing feelings of anger.
A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take? A) Compliment the client for weight gain. B) Allow the client to eat at any time. C) Provide privacy when friends visit. D) Schedule regular weigh-in times.
D) Schedule regular weigh-in times.
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) A) Seizures B) Illusions C) Tremors D) Polyphagia E) Nystagmus
A) Seizures B) Illusions C) Tremors
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding? A) "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol." B) "Alcohol tolerance causes me to have an increased effect when taking opiates." C) "I will develop a decreased physical response to alcohol." D) "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal."
C) "I will develop a decreased physical response to alcohol."
A client states, "I just don't know what to do about my partner's drinking. Every time I see him drinking beer, I start to feel extremely anxious." Which of the following is the most therapeutic response by the nurse? A) "Tell me more about what is going on with your son. Is he still causing problems for you?" B) "At one time you told me you were drinking regularly with your partner. Are you continuing to do that?" C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?" D) "I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."
C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?"
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? A) "The ritualistic behavior provides sexual satisfaction." B) "The client performs ritualistic behavior to boost self-esteem." C) "The ritualistic behavior temporarily relieves anxiety." D) "The client performs ritualistic behavior to decrease feelings of shame."
C) "The ritualistic behavior temporarily relieves anxiety."
A nurse is planning care for a client who has a prescription for alprazolam. For which of the following adverse effects should the nurse plan to monitor? A) Decreased urine output B) Manifestations of seizure activity C) Inability to recall events D) Increase in white blood cell count
C) Inability to recall events
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take? A) Encourage the client to go back to bed. B) Give the client a PRN sleeping medication. C) Remain with the client. D) Explore alternatives to pacing the floor with the client.
C) Remain with the client.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors? A) "Has alcohol use affected your performance at work?" B) "Have you received prior treatment for substance use disorder?" C) "Do you receive treatment for any mental health disorders?" D) "At what age did you begin drinking alcohol?"
A) "Has alcohol use affected your performance at work?"
A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should the nurse expect? A) Tremors B) Hypothermia C) Hypotension D) Respiratory depression
A) Tremors
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts? A) "I am responsible for my alcoholism." B) "I need to identify things that cause me to be an alcoholic." C) "I am powerless against my addiction to alcohol." D) "I need to see a counselor who will be responsible for my recovery."
C) "I am powerless against my addiction to alcohol."
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment? A) "I plan to sit on a park bench for a few minutes each day." B) "I can try participating in group therapy every week." C) "I will join a book club in my neighborhood." D) "I should avoid entering elevators and other closed spaces."
A) "I plan to sit on a park bench for a few minutes each day."
A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? A) Diazepam B) Acamprostate C) Naltrexone D) Disulfiram
A) Diazepam
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? A) Hand tremors B) Stuporous level of consciousness C) Bradycardia D) Hypotension
A) Hand tremors
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A) Identify the client's nutritional status. B) Request a mental health consult. C) Plan a therapeutic diet for the client. D) Provide a structured environment for the client.
A) Identify the client's nutritional status.
A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which of the following medications should the nurse plan to administer? A) Methadone B) Disulfiram C) Diazepam D) Buprenorphine
C) Diazepam
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety? A) Mild B) Moderate C) Severe D) Panic
C) Severe
A nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation? A) Assist the client in practicing meditation. B) Recognize the client's spiritual preferences. C) Encourage the client to identify his positive qualities. D) Help the client to identify his previous accomplishments.
A) Assist the client in practicing meditation.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following statements indicates understanding? A) "I should expect tremors to start less than 24 hours after I stop drinking." B) "Disulfiram will block my cravings for alcohol." C) "My symptoms should last about 5 to 7 days once they begin." D) "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
A) "I should expect tremors to start less than 24 hours after I stop drinking."
A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.) A) Amenorrhea B) Verbalized desire to gain weight C) Altered body image D) Hyperactivity E) Bradycardia
A) Amenorrhea C) Altered body image D) Hyperactivity E) Bradycardia
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.) A) Anxiety B) Obsessive-compulsive disorder C) Schizophrenia D) Breathing-related sleep disorder E) Depression
A) Anxiety B) Obsessive-compulsive disorder E) Depression
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following? A) Decrease anxiety. B) Prevent aggressive and impulsive behaviors. C) Manipulate others. D) Decrease the time available for interaction with people.
A) Decrease anxiety.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.) A) Difficulty relaxing B) Irrational fear of certain objects C) Rule-conscious behavior D) Unaware of compulsions E) Perfectionist behavior
A) Difficulty relaxing C) Rule-conscious behavior E) Perfectionist behavior
A nurse is caring for a client who has just begun therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication? A) Insomnia B) Bradycardia C) Hearing loss D) Hypertension
A) Insomnia
A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the nurse prepare to administer? A) Methadone B) Disulfiram C) Risperidone D) Lithium carbonate
A) Methadone
A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following clients should the nurse suggest offering the therapy to? A) Post-traumatic Stress Disorder B) Schizophrenia C) Pedophilia D) Paranoid personality disorder
A) Post-traumatic Stress Disorder
A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism? A) The client begins reading a book when he experiences hand tremors in response to loud noise. B) The client makes a decision to postpone a needed surgery. C) The client focuses on discussing his daily routine when asked about the fire. D) The client develops stomach pains when fire is seen on television.
A) The client begins reading a book when he experiences hand tremors in response to loud noise.
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A) Hyperactive bowel sounds B) Bradycardia C) Hypertension D) Dental erosion
B) Bradycardia
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? A) "I'm sure that the bugs you see will not harm you." B) "Tell me more about the bugs that you see in your room." C) "I don't see any bugs, but you seem very frightened." D) "I do not see anything. This is part of the withdrawal process."
C) "I don't see any bugs, but you seem very frightened."
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion? A) "I like to cut my food into small pieces." B) "I really need to get into shape." C) "If I eat one piece of candy, I may as well eat ten." D) "I can't afford to gain weight."
C) "If I eat one piece of candy, I may as well eat ten."
A nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize as a maladaptive defense mechanism? A) A client slams a drawer after misplacing her wallet. B) A man buys his partner a gift after flirting with his secretary. C) A client forgets to schedule needed appointments when fearing chemotherapy. D) A client ignores the thought of pain when scheduled for oral surgery.
C) A client forgets to schedule needed appointments when fearing chemotherapy.
A nurse is caring for a client who has severe manifestations of acute alcohol withdrawal. To ensure safe care, which of the following nursing actions should the nurse take? (Select all that apply.) A) Administer a sedative. B) Keep the lights on in the client's room. C) Ambulate the client in the hallway. D) Reduce unnecessary stimuli. E) Limit daily fluid intake.
C) Ambulate the client in the hallway. D) Reduce unnecessary stimuli.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A) Muscle aches and chills B) Fatigue and depression C) Anxiety and diaphoresis D) Arrhythmia and respiratory depression
C) Anxiety and diaphoresis
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess? A) Amylase B) Creatinine C) Aspartate aminotransferase (AST) D) Antidiuretic hormone (ADH)
C) Aspartate aminotransferase (AST)
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors? A) Isolate the client for a period of time. B) Confront the client about the senseless nature of the repetitive behaviors. C) Plan the client's schedule to allow time for rituals. D) Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
C) Plan the client's schedule to allow time for rituals.
A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress? A) The client demonstrated an allergic response to the medication. B) The client experienced a common side effect to the medication. C) The client consumed alcohol while taking the medication. D) The client took an overdose of the medication.
C) The client consumed alcohol while taking the medication.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements? A) "I check any room I enter because the enemy is still after me and could be hiding anywhere." B) "My child was born with a birth defect due to an exposure I had overseas." C) "I killed four enemy soldiers with my bare hands and saved my entire battalion." D) "In my dreams, all I can see are the wounded reaching out and trying to grab me."
D) "In my dreams, all I can see are the wounded reaching out and trying to grab me."
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A) Increased vital capacity B) Moist skin C) Heat intolerance D) Decreased mental status
D) Decreased mental status
A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use? A) Projection B) Rationalization C) Repression D) Denial
D) Denial
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first? A) Call for assistance to place the client in restraints. B) Escort the client to an unlocked seclusion room. C) Offer the client a PRN antianxiety medication. D) Speak to the client calmly, giving simple directions.
D) Speak to the client calmly, giving simple directions.
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings to the nurse? A) The client is ready for discharge. B) The client may be having a recurrence of delirium tremens. C) The client is able to function independently. D) The client is exhibiting dependency.
D) The client is exhibiting dependency.
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam? A) The clients states, "I see purple bugs crawling on the wall." B) The client tells the nurse that he is too tired to attend the group meeting. C) The client tells the nurse he is a government agent. D) The client states, "My heart is pounding out of my chest."
D) The client states, "My heart is pounding out of my chest."
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority? A) The client will acknowledge alcohol dependence and need for treatment. B) The client will rebuild damaged interpersonal relationships. C) The client will implement alternative strategies for managing anxiety. D) The client's withdrawal from alcohol will be managed without complications.
D) The client's withdrawal from alcohol will be manager without complications.
A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations? A) Attention-seeking conduct B) Mild difficulty problem solving C) Mild fidgeting D) Threatening behavior
D) Threatening behavior
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day, and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of the following defense mechanisms? A) Repression B) Splitting C) Sublimation D) Undoing
D) Undoing
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? A) Rapid speech B) Chills C) Distorted perceptual field D) Urinary frequency
D) Urinary frequency
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? A) Instruct the client to sit down and stop pacing. B) Allow the client to pace alone until physically tired. C) Have a staff member escort the client to her room. D) Walk with the client at a gradually slower pace.
D) Walk with the client at a gradually slower pace.
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take? A) Praise the client for looking at herself in a mirror. B) Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. C) Reprimand the client about the potential damage that has occurred due to overexcercising her body. D) Restrict the client from being weighed.
B) Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? A) Conversion B) Projection C) Undoing D) Regression
B) Projection
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? A) Helping the client identify positive personality traits B) Providing for adequate hydration and rest C) Confronting the use of denial and other defense mechanisms. D) Educating the client about the consequences of alcohol misuse
B) Providing for adequate hydration and rest
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply). A) Severe hypotension B) Visual hallucinations C) Hyperglycemia D) Insomnia E) Tremors
B) Visual hallucinations D) Insomnia E) Tremors
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? A) Prior physical health followed by the need for two surgeries within the last three months. B) Obsession over a fictitious defect in physical appearance. C) Sudden unexplained loss of peripheral sensation. D) Constant worry about the undiagnosed presence of an illness.
D) Constant worry about the undiagnosed presence of an illness
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? A) Limit the amount of time available to interact with others. B) Focus attention on meaningful tasks. C) Manipulate and control others' behaviors. D) Decrease anxiety to a tolerable level.
D) Decrease anxiety to a tolerable level.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? A) Xenophobia B) Acrophobia C) Mysophobia D) Agoraphobia
D) Agoraphobia
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan? A) Contact the crisis counselor once a week. B) Identify anxiety-producing situations. C) Try to repress feelings of anxiety. D) Eliminate stress and anxiety from daily life.
B) Identify anxiety-producing situations.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? A) Discuss alternative coping strategies with the client. B) Identify precipitating factors for ritualistic behaviors. C) Instruct the client on relaxation techniques for use when anxiety increases. D) Provide a structured activity schedule for the client.
B) Identify precipitating factors for ritualistic behaviors.
A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take? A) Prevent the client from performing compulsive behavior. B) Investigate what situations precipitate anxiety. C) Encourage avoidance of situations that increase anxiety. D) Teach the client that compulsive behavior is excessive.
B) Investigate what situations precipitate anxiety.
A nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survivor guilt, and difficulty concentrating. Which of the following diagnoses describe the client's symptoms? A) Generalized anxiety disorder B) Post-traumatic stress syndrome C) Histrionic personality disorder D) Dissociative identity syndrome
B) Post-traumatic stress syndrome
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first? A) Administer diazepam. B) Raise the side rails of the bed. C) Obtain a medical history. D) Start intravenous fluids.
B) Raise the side rails of the bed.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms? A) Dissociation B) Introjection C) Regression D) Repression
C) Regression
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms? A) Reaction-formation B) Compensation C) Rationalization D) Suppresion
C) Rationalization
A nurse is assessing four clients for indications of general adaptation syndrome (GAS). Which of the following clients should the nurse monitor closely for GAS? A) A 68-year-old client who has viral pneumonia. B) A 22-year-old client who has type 1 diabetes mellitus. C) A 59-year-old client who has Stage II Alzheimer's disease. D) A 40-year-old client who has ulcerative colitis.
D) A 40-year-old client who has ulcerative colitis.
