Final Review
Debra has been laughing, talking rapidly, with pressured speech. She is running from one part of the unit to the other. Her interactions with the staff and patients are abrupt, and sometimes she violates the individual's personal space. What nursing intervention is appropriate? A. Offer a PRN medication B. Offer seclusion C. Offer restraints D. Offer to pace with the patient
A. Offer a PRN medication
When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You're having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too."
C. "You're having difficulty sleeping?"
You are the nurse teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in: A. Abdominal cramps and diarrhea. B. Drowsiness and decreased respiration. C. Flushing, vomiting, and dizziness. D. Increased pulse and blood pressure.
C. Flushing, vomiting, and dizziness
The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique? A. To reframe the client's thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation
C. To explore a subject, idea, experience, or relationship
The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety? A. "I guess you're worried about something, aren't you? B. "Can I get you some medication to help calm you?" C. "Have you been pacing for a long time?" D. "I notice that you're pacing. How are you feeling?"
D. "I notice that you're pacing. How are you feeling?"
Patients have amenorrhea with the following eating disorder: A. Bulimia nervosa B. Binge eating C. Normal dieting D. Anorexia nervosa
D. Anorexia nervosa
A client with borderline personality disorder continually interrupts the nursing staff, disrupting the work with other clients. What is the most therapeutic response to be made to the client? a. Ask the client to leave the group b. Work one on one with the client c. Remind the client to work with the assigned nurse d. Tell the client to only talk to the therapist
c. Remind the client to work with the assigned nurse
You are caring for a client with schizotypal personality disorder. Which initial activity is most therapeutic for the client? a. Leading an activity in the day room b. Playing cards with another client c. Participating in a planned unit activity d. Attending an activity with the nurse
d. Attending an activity with the nurse
A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. "Touch carries a different meaning for different individuals." B. "Touch is often used when deescalating volatile client situations." C. "Touch is used to convey interest and warmth." D. "Touch is best combined with empathy when dealing with anxious clients."
"Touch carries a different meaning for different individuals."
The nurse is evaluating care of a client with schizophrenia; the nurse should keep which point in mind? 1. Frequent assessment is needed 2. The family does not need to be included as the patient is an adult 3. The patient is too ill to learn about his illness 4. Relapse is not an issue for a schizophrenic patient
1. Frequent assessment is needed
When a client experiences a panic attack, which outcome takes priority? 1. The client will remain safe throughout the duration of the panic attack. 2. The client will verbalize an anxiety level less than 2/10. 3. The client will use learned coping mechanisms to decrease anxiety. 4. The client will verbalize the positive effects of exercise by day
1. The client will remain safe throughout the duration of the panic attack.
The nurse has received evening report. Which client would the nurse need to assess first? 1. A newly admitted client with a history of panic attacks. 2. A client who slept 2 to 3 hours last night because of flashbacks. 3. A client pacing the halls and stating that his anxiety is an 8/10. 4. A client diagnosed with generalized anxiety disorder awaiting discharge.
3. A client pacing the halls and stating that his anxiety is an 8/10.
A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? A "I get upset once in a while, too." B "I know just how you feel. I'd feel the same way in your situation." C "I worry, too, when I think people are talking about me." D "At times, it's normal not to trust anyone."
A "I get upset once in a while, too."
A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? A "That must be frightening to you. Can you tell me how you feel about it?" B "There are no people living on Mars." C "What do you mean when you say they're going to invade the earth?" D "I know you believe the earth is going to be invaded, but I don't believe that."
A "That must be frightening to you. Can you tell me how you feel about it?"
A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? A "Your behavior won't be tolerated. Go to your room immediately." B "You're just doing this to get back at me for making you come to therapy." C "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." D "I'm disappointed in you. You can't control yourself even for a few minutes."
A "Your behavior won't be tolerated. Go to your room immediately."
During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"
A. "Are you being threatened or hurt by your partner?"
Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. "Can you tell me why you said that?" B. "Keep your chin up. I'll explain the procedure to you." C. "There is always an explanation for both good and bad behaviors." D. "Are you not understanding the explanation I provided?"
A. "Can you tell me why you said that?"
During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? A. "Don't worry. Everything will be alright." B. "You appear uptight." C. "I notice you have bitten your nails to the quick." D. "You are jumping to conclusions."
A. "Don't worry. Everything will be alright."
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors ask the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the MOST APPROPRIATE nursing response? A. "I can not discuss any patient situation with you." B. "If you want to know about Mary, you need t ask her yourself." C. "Only because you're worried about a friend, I'll tell you that she is improving." D. "Being her friend, you know she is having a difficult time and deserves her privacy."
A. "I can not discuss any patient situation with you."
A client is struggling to explore and solve a problem. Which nursing statement would verbalize the implication of the client's actions? A. "You seem to be motivated to change your behavior." B. "How will these changes affect your family relationships?" C. "Why don't you make a list of the behaviors you need to change." D. "The team recommends that you make only one behavioral change at a time."
A. "You seem to be motivated to change your behavior."
14. Which of the following individuals are communicating a message? (Select all that apply.) A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, "No one understands me." E. A father checking for new e-mail on a regular basis
A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, "No one understands me."
You are caring for a client who is diagnosed with moderate dementia has frequent catastrophic reactions during shower time. Which of the following interventions should be implemented in the plan of care? Select all that apply. A. Assign consistent staff members to assist the client. B. Accomplish the task quickly, with several staff members assisting. C. Schedule the client's shower at the same time of day. D. Sedate the client 30 minutes prior to showering. E. Tell the client to remain calm while showering. F. Use a calm, supportive, quiet manner when assisting the client.
A. Assign consistent staff members to assist the client. C. Schedule the client's shower at the same time of day. F. Use a calm, supportive, quiet manner when assisting the client.
A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: A. Check the client frequently at irregular intervals throughout the night. B. Assure the client that the nurse will hold in confidence anything the client says. C. Repeatedly discuss previous suicide attempts with the client. D. Disregard decreased communication by the client because this is common with suicidal clients.
A. Check the client frequently at irregular intervals throughout the night.
A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take INITIALLY? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportations. C. Attempt to persuade the patient to stay for only a few more days. D. Tell the patient that leaving would likely result in an involuntary commitment.
A. Contact the patient's health care provider (HCP).
A patient admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting. "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the patient implementing? A. Denial B. Projection C. Regression D. Rationalization
A. Denial
A patient being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? A. Denial B. Projection C. Rationalization D. Intellectualization
A. Denial
A client tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. A. Help the client to develop a plan to ensure safety, including phone numbers for emergency help. B. Help the client to get her boyfriend into an appropriate treatment program. C. Communicate acceptance, avoiding any implication that the client is at fault for not leaving. D. Help the client to explore available options, including shelters and legal protection. E. Tell the client that she should leave because things will not improve. F. Reinforce concern for the client's safety and her right to be free of abuse.
A. Help the client to develop a plan to ensure safety, including phone numbers for emergency help. C. Communicate acceptance, avoiding any implication that the client is at fault for not leaving. D. Help the client to explore available options, including shelters and legal protection. F. Reinforce concern for the client's safety and her right to be free of abuse.
Kyle is a client with an anxious, fearful personality who has difficulty accomplishing work assignments because of his fear of failure. He has been referred to the employee assistance program because of repeated absences from work and evidence of an alcohol problem. Which nursing problem would be most appropriate? A. Ineffective coping B. Decisional conflict C. Disturbed thought process D. Risk for self-directed violence
A. Ineffective coping
Nurse Florence assesses Mrs. B with borderline personality disorder. Which of the following behaviors are common to this diagnosis? Select all that apply. A. Intense fear of being alone B. Evidence of self-mutilating attempts C. Evidence of suspiciousness and mistrust of others D. Indifferent attitude toward approval of criticism E. Unstable moods with impulsive behaviors F. Presence of odd mannerisms, speech, and behaviors
A. Intense fear of being alone B. Evidence of self-mutilating attempts E. Unstable moods with impulsive behaviors
When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission. C. Supply the patient with written information about their mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed.
A. Monitor closely for harm to self or others.
The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? Select all that apply. A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval
A. Restating B. Listening D. Maintaining neutral responses E. Providing acknowledgment and feedback
What are adolescent manifestations of childhood sexual abuse? A. Self-destructive behaviors B. Overly attached to one's family C. Developing good interpersonal relationships D. Planning to marry childhood sweetheart
A. Self-destructive behaviors
A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful? A. The parents reinforce increased decision making by the client. B. The parents clearly verbalize their expectations for the client. C. The client verbalizes that family meals are now enjoyable. D. The client tells her parents about feelings of low self-esteem.
A. The parents reinforce increased decision making by the client.
For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children
A. They tend to overprotect their children
A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the use to encourage the patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition
A. Using open-ended questions and silence
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response? A. "Do you believe that I was the cause of your blood test being canceled?" B. "I see that you are upset, but I feel uncomfortable when you swear at me." C. "Have you ever thought about ways to express anger appropriately?" D. "I'll give you some space. Let me know if you need anything."
B. "I see that you are upset, but I feel uncomfortable when you swear at me."
Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. "My sister has the same diagnosis as you and she also hear voices." B. "I understand that the voices seem real to you, but I do not hear any voices." C. "Why not turn up the radio so that the voices are muted." D. "I wouldn't worry about these voices. The medication will make them disappear."
B. "I understand that the voices seem real to you, but I do not hear any voices."
A student nurse tells the instructor, "I'm concerned that when a client asks me for advice I won't have a good solution." Which should be the nursing instructor's best response? A. "It's scary to feel put on the spot by a client. Nurses don't always have the answer." B. "Remember, clients, not nurses, are responsible for their own choices and decisions." C. "Just keep the client's best interests in mind and do the best that you can." D. "Set a goal to continue to work on this aspect of your practice."
B. "Remember, clients, not nurses, are responsible for their own choices and decisions."
A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."
B. "Tell me how you feel about the accident."
An 82-year-old client, together with his daughter, arrived at the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? A. "Maybe it's just caused by aging. This usually happens by age 82." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." D. "Dad has always been so independent. He's lived alone for years since mom died.
B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
Which nursing statement is a good example of the therapeutic communication technique of offering self? A. "I think it would be great if you talked about that problem during our next group session." B. "Would you like me to accompany you to your electroconvulsive therapy treatment?" C. "I notice that you are offering help to other peers in the milieu." D. "After discharge, would you like to meet me for lunch to review your outpatient progress?"
B. "Would you like me to accompany you to your electroconvulsive therapy treatment?"
15. A mother rescues two of her four children from a house fire. In the emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? A. "The smoke was too thick. You couldn't have gone back in." B. "You're feeling guilty because you weren't able to save your children." C. "Focus on the fact that you could have lost all four of your children." D. "It's best if you try not to think about what happened. Try to move on."
B. "You're feeling guilty because you weren't able to save your children."
Anthony has become more depressed during the hospitalization. He is fearful that he will never see his child and that his relationship with his girlfriend is over. He is feeling scared that he has no where to live. Anthony began to think about suicide as a means of dealing with these overwhelming feelings. He mentioned he wants to hang himself to one of his peers on the unit. What would be the best nursing action? A. Ask Anthony to stay in the seclusion room where there are no sheets to hang himself. He is placed on one-to-one. B. Ask Anthony questions about his suicidal intent and how he plans to carry out his plans. He is placed on one-to-one. C. Ask Anthony to consider what committing suicide would do to his child and girlfriend. He continues on every 15-minute checks. D. Ask Anthony to call his mother to reduce his isolation and provide some support if she is able to do so. He is placed on one-to-one.
B. Ask Anthony questions about his suicidal intent and how he plans to carry out his plans. He is placed on one-to-one.
The nurse calls security and has physical restraints applied when a client who admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. A. Libel B. Battery C. Assault D. Slander E. False Imprisonment
B. Battery C. Assault E. False Imprisonment
Kendall, the sister of a client with a substance-related disorder, tells the nurse she calls out sick for her sister Kylie occasionally when the latter has too much to drink and cannot work. This behavior can be described as: A. Caretaking. B. Codependent. C. Helpful. D. Supportive.
B. Codependent.
Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using? A. Compensation B. Denial C. Suppression D. Undoing
B. Denial
In a day treatment program, a manic client is creating considerable chaos, behaving in a dominating and manipulative way. Which nursing intervention is most appropriate? A. Allow the peer group to intervene. B. Describe acceptable behavior and set realistic limits with the client. C. Recommend that the client is hospitalized for treatment. D. Tell the client that his behavior is inappropriate.
B. Describe acceptable behavior and set realistic limits with the client.
Which of the following client behaviors documented in a client's chart would validate the nursing concern of risk for other-directed violence? A. Description of being endowed with superpowers. B. Frequent angry outburst noted toward peers and staff. C. Refusal to eat cafeteria food. D. Refusal to join in group activities.
B. Frequent angry outburst noted toward peers and staff.
You are assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? A. Flexible role functioning between parents B. History of the parent having been abused as a child C. Single-parent home situation D. Presence of parental mental illness
B. History of the parent having been abused as a child
The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is MOST APPROPRIATE for this phase? A. Planning short-term goals B. Making appropriate referrals C. Developing realistic solutions D. Identifying expected outcomes
B. Making appropriate referrals
What are current medications used to treat ADHD? A. Fluvoxamine (Luvox) B. Methylphenidate (Concerta) C. Buspirone (BuSpar) D. Risperidone (Risperdal)
B. Methylphenidate (Concerta)
Amanda has benefited from the short-term hospital stay. She feels more hopeful and has begun to plan how to obtain another job. She has reconnected with her son and family members. What follow-up information must the nurse give Amanda before discharge? A. Provide a peer-to-peer counselor B. Provide suicide hotline number: 1-800-273-TALK C. Provide a support group resource D. Provide information on depression
B. Provide suicide hotline number: 1-800-273-TALK
A client slammed a door on the unit several times. The nurse responds, "You seem angry." The client states, "I'm not angry." What therapeutic communication technique has the nurse employed and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement
B. Verbalizing the implied and the defense mechanism of denial
Barbara is a client with borderline personality disorder. She is defensive and emotionally labile and often becomes suddenly and explosively angry. When interacting with her, you as a nurse would: A. point out how angry Barbara is becoming, and confront the behavior. B. take a calm, quiet, and nonconfrontational approach, and avoid arguing with Barbara. C. tell Barbara to calm down and to avoid becoming explosive or restraints will be used. D. Use a gentle touch and a caring approach to calm Barbara.
B. take a calm, quiet, and nonconfrontational approach, and avoid arguing with Barbara.
Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond? A "Why do you think there is a bomb in the elevator?" B "That is the same thing you said in yesterday's session." C "I know you think there are bombs in the elevator, but there aren't." D "If you have something to say, you must do it according to our group rules."
C "I know you think there are bombs in the elevator, but there aren't."
A nursing assessment of an individual suspected of having a substance-related disorder should include A. "Have you been able to sleep well in the last few days?" B. "Has your mood changed from depressed to euphoric recently?" C. "Are you experiencing frequent absenteeism at work, especially after weekends?" D. "Are you having marital issues related to financial pressures?"
C. "Are you experiencing frequent absenteeism at work, especially after weekends?"
Which statement demonstrates the BEST understanding of the nurse's role regarding ensuring that each client's rights are respected? A. "Autonomy is the fundamental right of each and every client." B. "A patient's rights are guaranteed by both state and federal laws." C. "Being respectful and concerned will ensure that I'm attentive to my patient's rights." D. "Regardless of the patient's conditions, all nurses have the duty to respect patient rights."
C. "Being respectful and concerned will ensure that I'm attentive to my patient's rights."
A patient 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? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family." C. "You're feeling angry that your family continues to hope for you to be cured?" D. "You are probably very depressed, which is understandable with such a diagnosis."
C. "You're feeling angry that your family continues to hope for you to be cured?"
A client on an in-patient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response? A. "How would your family feel if you died?" B. "You feel worthless now, but that can change with time." C. "You've been feeling sad and alone for some time now?" D. "It is great that you have come in for help."
C. "You've been feeling sad and alone for some time now?"
A patient is taking amitriptyline 75 mg at night for a depression. He reports having a dry mouth, blurred vision, and constipation. What is causing these side effects? A. CNS side effects B. Antiadrenergic effects C. Anticholinergic effects D. Cardiovascular effects
C. Anticholinergic effects
Which nursing action would the nurse do first when working with an individual with borderline personality disorder? A. Set limits. B. Determine boundaries. C. Assess for self-harm. D. Assess relationship system
C. Assess for self-harm.
The body weight is likely to be normal for a patient with the following: A. Normal eating patterns B. Binge eating disorder C. Bulimia nervosa D. Anorexia nervosa
C. Bulimia nervosa
Rendell is admitted in an acute psychiatric unit at Nurseslabs Medical Center. He suddenly tells Nurse Matt about his plans for suicide. The nurse's priority is to: A. Allow the client time alone for reflection. B. Encourage the client to use problem solving. C. Follow agency protocol for suicide precautions. D. Stimulate the client's interest in activities.
C. Follow agency protocol for suicide precautions.
Which of the following is a common symptom of ADHD? A. Apathy B. Psychotic thinking C. Hyperactivity D. Hypersomnia
C. Hyperactivity
Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day
C. Identify anxiety-causing situations
A nursing student is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is: A. Assess the scope of the abuse problem. B. Analyze family dynamics. C. Implement measures to ensure the victim's safety. D. Teach appropriate coping skills.
C. Implement measures to ensure the victim's safety.
Often, substance-related disorders are associated with the following: A. Severe dementia B. Pica C. PTSD D. Anorexia
C. PTSD
Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability? A. Attempt humor to alter the client mood. B. Explore reasons for the client's altered mood. C. Reduce environmental stimuli to redirect the client's attention. D. Use logic to point out reality aspects.
C. Reduce environmental stimuli to redirect the client's attention.
An elderly client with Alzheimer's disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. Tell the client family that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm and talk quietly to the client. D. Call the doctor and request an order for sedation.
C. Remain calm and talk quietly to the client.
Nurse Rob has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co-worker? A. Ignore the co worker's behavior, and frequently assess the clients assigned to the co-worker. B. Make general statements about safety issues at the next staff meeting. C. Report the coworker's behavior to the appropriate supervisor. D. Warn the co-worker that this practice is unsafe.
C. Report the coworker's behavior to the appropriate supervisor.
A 75-year-old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer's type and depression. The symptom that is unrelated to depression would be? A. Apathetic response to the environment B. "I don't know" answer to questions C. Shallow of labile effect D. Neglect of personal hygiene
C. Shallow of labile effect
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered PRN buspirone (BuSpar
C. Stay with the client and offer reassurance of safety
In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: A. Aphasia. B. Agnosia. C. Sundowning. D. Confabulation.
C. Sundowning.
Nurse Nadine is assessing James who is diagnosed with bipolar disorder. The nurse would expect to find a history of: A. A depressive episode followed by prolonged sadness. B. A series of depressive episodes that recur periodically. C. Symptoms of mania that may or may not be followed by depression. D. Symptoms of mania that include delusional thoughts.
C. Symptoms of mania that may or may not be followed by depression.
A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse.
C. The child doesn't cry when the shoulder is examined
A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care? A. The client will have no flashbacks. B. The client will be able to feel a full range of emotions by discharge. C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. D. The client will refrain from discussing the traumatic event.
C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the shower head. They'll kill me if I take a shower." Which nursing action is most appropriate? A Dismantling the showerhead and showing the client that there is nothing in it B Explaining that other clients are complaining about the client's body odor C Asking a security officer to assist in giving the client a shower D Accepting these fears and allowing the client to take a sponge bath
D Accepting these fears and allowing the client to take a sponge bath
A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? A. "Does your husband treat you like this very often?" B. "What do you think is your role in this relationship?" C. "Why do you think he behaved like that?" D. "Describe what happened during your time with your husband."
D. "Describe what happened during your time with your husband."
During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you had sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." B. "It is important for you to discontinue these ritualistic behaviors." C. "Why are you asking for help if you won't participate in unit therapy?" D. "Let's figure out a way for you to attend unit activities and still wash your hands."
D. "Let's figure out a way for you to attend unit activities and still wash your hands."
Which nursing statement is a good example of the therapeutic communication technique of focusing? A. "Describe one of the best things that happened to you this week." B. "I'm having a difficult time understanding what you mean." C. "Your counseling session is in 30 minutes. I'll stay with you until then." D. "You mentioned your relationship with your father. Let's discuss that further."
D. "You mentioned your relationship with your father. Let's discuss that further."
A patient with a diagnosis of major 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 response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"
D. "You've been feeling like a failure for a while?"
On review of the patient's record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient behavior? A. Fearfulness regarding treatment measures. B. Anger and aggressiveness directed toward others. C. An understanding of the pathology and symptoms of the diagnosis. D. A willingness to participate in the planning of the care and treatment plan.
D. A willingness to participate in the planning of the care and treatment plan.
A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A. Memory loss occurring as part of the natural consequence of aging B. Difficulty coping with physical and psychological change C. Severe cognitive impairment that occurs rapidly D. Loss of cognitive abilities, impairing ability to perform activities of daily living
D. Loss of cognitive abilities, impairing ability to perform activities of daily living
Mrs. Smith was admitted to the emergency department with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? A. Mrs. Smith's explanation is appropriate acceptance of her responsibility. B. Mrs. Smith's explanation is an atypical reaction of an abused woman. C. Mrs. Smith's explanation is evidence that the woman may be an abuser as well as a victim. D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.
D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.
Debra has not been able to eat sufficient calories to sustain her increased activity. What nursing intervention would assist her? A. Provide a larger high-calorie meal. B. Distract her to encourage eating. C. Provide an increase in high-calorie snacks. D. Provide frequent portable food items.
D. Provide frequent portable food items.
Clara is under evaluation for imminent suicide risk, which information given by her would be most significant? A. At least a 2-year history of feeling depressed more days than not B. Divorced from spouse six (6) months ago C. Feeling loss of energy and appetite D. Reference to suicide as best solution to identified problems
D. Reference to suicide as best solution to identified problems
Which of the following will the nurse use when communicating with a client who has a cognitive impairment? A. Complete explanations with multiple details B. Picture or gestures instead of words C. Stimulating words and phrases to capture the client's attention D. Short words and simple sentences
D. Short words and simple sentences
Nurse Marge teaches the family of a client with major depression disorder. Which of the following information should be included in the teaching? Select all that apply. A. Depression is characterized by sadness, feelings of hopelessness, and decreased self-worth B. It is common for a pressed individual to have thoughts of suicide. C. Attempts to cheer up a person with depression are often helpful. D. Talk therapy, along with antidepressant medications, is usually the treatment. E. Someone with depression may be preoccupied with spending money and too busy to sleep. F. Encourage a person with depression to keep a regular routine of activity and rest.
D. Talk therapy, along with antidepressant medications, is usually the treatment. F. Encourage a person with depression to keep a regular routine of activity and rest.
A patient's unresolved feelings related to loss would be MOST LIKELY observed during which phase of the therapeutic nurse-patient relationship? A. Trusting B. Working C. Orientation D. Termination
D. Termination
On a substance abuse unit, a client diagnosed with cirrhosis of the liver tells the nurse, "I really don't believe that drinking a couple of cocktails every night has anything to do with my liver problems." What is the nurse's best response? a. "You find it hard to believe that drinking alcohol can damage the liver?" b. "How long have you been drinking a couple of cocktails a night?" c. "If not by alcohol, explain how your liver became damaged?" d. "Everyone knows that increased alcohol consumption can damage your liver"
a. "You find it hard to believe that drinking alcohol can damage the liver?"
A client on a psychiatric unit tells the nurse, "I am all alone in the world right now, and I have no reason to live." Which response by the nurse would encourage further communication by the client? a. "You sound like you are feeling lonely and frustrated." b. "Why do you think that suicide is the answer to your loneliness?" c. "I live by myself and know it can be very lonely and frustrating." d. "Just hang in there and, you'll see, things will work out."
a. "You sound like you are feeling lonely and frustrated."
An elderly woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. She says to the nurse who offers her breakfast, "Oh no, I will wait for my husband. We will eat together" The therapeutic response by the nurse is: a. "Your husband is dead. Let me serve you your breakfast." b. "I've told you several times that he is dead. It's time to eat." c. "You're going to have to wait a long time." d. "What made you say that your husband is alive?
a. "Your husband is dead. Let me serve you your breakfast."
A client diagnosed with bipolar disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? a. Calmly redirect and remove the client from the milieu. b. Administer a prescribed prn intramuscular injection for agitation. c. Ask the client to lower his voice while in the common area. d. Obtain an order for seclusion to help decrease external stimuli.
a. Calmly redirect and remove the client from the milieu.
You are assessing a client with avoidant personality disorder. Which information is most important in regard to the diagnosis? (Select all that apply) a. The client states that he has no friends b. The client is able to give a presentation at work c. The client is shy and cannot interact with people d. The client readily tries new things e. The client struggles with relationships
a. The client states that he has no friends c. The client is shy and cannot interact with people e. The client struggles with relationships
An antisocial client has a history of being involved with the law, has problems with relationships and has begun yelling at the nurse. Which behavior requires immediate attention? a. Yelling at the nurse b. Discussing past history of issues with the police c. Bringing up previous relationship problems d. Refusing to participate in unit activities
a. Yelling at the nurse
Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response? a. Confront the delusional material directly by telling Gio that this simply is not so. b. Tell Gio that this must seem frightening to him but that you believe he is safe here. c. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions. d. Isolate Gio when he begins to talk about these beliefs.
b. Tell Gio that this must seem frightening to him but that you believe he is safe here.
A client was admitted to an inpatient psychiatric unit 4 days ago for the treatment of obsessive-compulsive disorder. Which outcome takes priority for this client at this time? a. The client will use a thought stopping technique to eliminate obsessive and or compulsive behaviors. b. The client will stop obsessive and or compulsive behaviors in order to focus on activities of daily living. c. The client will seek assistance from the staff to decrease obsessive and or compulsive behaviors. d. The client will use one relaxation technique to decrease obsessive and or compulsive behaviors.
c. The client will seek assistance from the staff to decrease obsessive and or compulsive behaviors.
The family of a schizophrenic client asks the nurse if there is a genetic cause of this disorder. To answer the family, which fact would the nurse cite? a. Conclusive evidence indicates a specific gene transmits the disorder. Incidence of this disorder is variable in all families. c. There is a little evidence that genes play a role in transmission. d. Genetic factors can increase the vulnerability for this disorder.
c. There is a little evidence that genes play a role in transmission.
Which statement by the client during the initial assessment in the emergency department is most indicative of suspected domestic violence? a. "I am determined to leave my house in a week." b. "No one else in the family has been treated like this." c. "I have only been married for two (2) months." d. "I have tried leaving, but have always gone back."
d. "I have tried leaving, but have always gone back."
A female client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? a. Enter the room quietly and move beside her to assess her injuries. b. Call for staff back-up before entering the room and restraining her. c. Move as much glass away from her as possible and sit next to her quietly. d. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.
d. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.
You suspect a patient brought to the ED has overdosed on opioids. Which assessment finding would require immediate attention: a. BP 90/60 b. Pulse 110 c. Decreased level of consciousness d. RR 6
d. RR 6
