HESI practice questions
Which statement made by a severely depressed client requires the nurse's immediate attention? a. "Feeling better really isn't important to me anymore." b. "No one can really understand what I've had to deal with." c. "I really don't like the way that new depression pill makes me feel." d. "I've not been the least bit interested in socializing since my divorce."
feeling better really isn't important to me anymore Rationale: The suicidal client may subtly express the intention to harm oneself in the form of a covert suicidal threat. The statement in option A should receive the nurse's priority attention because it is directly related to the client's safety. The remaining options are not related to safety as directly. Test-Taking Strategy(ies): Note the strategic word, immediate, and focus on the subject, the client statement that requires immediate attention. Note that the client is severely depressed. Therefore, select the option that is directly related to the client's safety.
A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1. Assess the client's vital signs. 2. Identify the client's activity during the pain. 3. Assess for signs related to a panic disorder. 4. Determine the client's use of relaxation techniques.
assess the client's vital signs Rationale: Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority. Test-Taking Strategy(ies): Note the strategic word, priority, and use Maslow's Hierarchy of Needs theory. Recall that physiological needs are the priority. This will direct you to the correct option. Also note that the incorrect options are comparable and alike in that they are not associated with any physical signs or symptoms.
A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy? 1. Fosters positive behavioral change 2. Develops structure and organizes time 3. Creates insight into maladaptive behavior 4. Decreases stress through relaxation training
fosters positive behavioral change Rationale: The purpose of behavioral therapy is to create effective changes in behavior. Developing structure and organizing time describe aspects of milieu management. Insight is a useful outcome of psychotherapy but does not always result in behavior change. Relaxation training is a treatment modality effective for reducing stress. Test-Taking Strategy(ies): Focus on the subject, behavioral therapy, and think about what it entails; this will direct you to the correct option. Also note the word behavioral in the question and correct option.
A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? 1. Obtaining feedback from the client about the coping abilities of the caregiver 2. Gathering subjective and objective assessment from the caregiver and the client 3. Making a referral to the home care agency social worker to complete the assessment 4. Interviewing family members regarding their concerns for the health and well-being of the caregiver
gathering subjective and objective assessment from the caregiver and the client Rationale: Caregiver strain can occur when a client is significantly dependent on someone else for personal and health care needs. To assess for caregiver strain, the nurse should gather subjective and objective data from the caregiver and the client. The nurse should not expect the client or family members to assess the coping abilities of the caregiver. Although a social worker may be helpful, the nurse needs to perform the assessment of the situation before making the referral. Test-Taking Strategy(ies): Use the steps of the nursing process, remembering that assessment is the first step. This will assist in eliminating option 3. Next, eliminate options that suggest unreliable assessment methods. Also note that the correct option addresses assessment of both the client and the caregiver.
An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury? 1. Turn off the television and radio, and use a night-light. 2. Keep soft lighting and the television on during the night. 3. Change the client's room to one nearer the nurses' station. 4. Play soft instrumental music all night, and do not turn down the lights.
turn off the television and radio, and use a night-light Rationale: A night-light is needed for client safety to reduce the risk of falls if the client should get out of bed unattended. It is important to reduce environmental stimulation and provide a consistent daily routine for a disoriented client. Noise levels, including radio and television, may add to the confusion and disorientation. Moving the client to a room near the nurses' station is not the first action. Test-Taking Strategy(ies): Note the strategic words, most important, in the question. Focusing on the subject, managing delirium, will direct you to the correct option, the one that will reduce environmental stimulation.
A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time? 1. "What is causing you to behave so agitated?" 2. "Why are you intent on upsetting the other clients?" 3. "Please stop so I don't have to put you in seclusion." 4. "You are going to be restrained if you do not change your behavior."
what is causing you to behave so agitated Rationale: The appropriate response is to ask the client what is causing the anger. This helps make the client aware of the behavior and may assist the nurse in planning appropriate interventions. Asking why is confrontational and could further escalate the client's behavior. The remaining options constitute threats to the client, which are inappropriate. Test-Taking Strategy(ies): Eliminate threatening options (options 3 and 4) because they are comparable or alike and nontherapeutic. Choose the correct option because it uses therapeutic communication techniques and promotes communication between the client and nurse.
A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? 1. Coarse hand tremor, agitation, hallucinations, and hypotension 2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3. Hypotension, stupor, agitation, headache, and auditory hallucinations 4.Fever, hypertension, changes in level of consciousness, and hallucinations
Fever, hypertension, changes in level of consciousness, and hallucinations Rationale: The symptoms associated with delirium tremens (DTs) typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions. Therefore, the remaining options are incorrect. Test-Taking Strategy(ies): Focus on the subject, signs/symptoms of DTs. To answer this question correctly, you must be familiar with the manifestations of DTs. Recall that hypertension occurs with DTs to assist you in answering correctly.
The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond? 1. "I need to continue with my visits since this disease tends to run in families." 2. "I agree with you that the medication will greatly reduce the risk for suicidal behavior." 3. "I agree with you that continuing to visit would reintroduce the possibility of suicidal ideations." 4. "I need to continue visiting since the client may now have the energy to act on suicidal intentions."
I need to continue visiting since the client may now have the energy to act on suicidal intentions Rationale: Most suicides occur within 3 months after the beginning signs of improvement, when the client has the energy to carry out suicidal intentions. The remaining options are incorrect because they fail to address safety and provide false information. Test-Taking Strategy(ies): Focus on the subject, suicide risk. Use knowledge regarding the facts about suicide to answer the question. Recalling that a critical time for a suicidal client is when the client has energy will direct you to the correct option.
Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1. "What makes you think that I am a vampire?" 2. "I'll leave and come back later for the specimen." 3. "Do you remember discussing the lab work earlier?" 4. "It must be frightening to think that others want to hurt you."
It must be frightening to think that others want to hurt you Rationale: The correct option helps the client focus on the emotion underlying the delusion but does not argue with it. Avoid statements that place the client in a position that requires a response. Attempting to avoid the situation will not address the client's anxiety. The incorrect responses may cause the client to hold the delusion more strongly. Test-Taking Strategy(ies): Use therapeutic communication techniques and knowledge of the subject, managing delusional thinking, to answer the question. The correct option is the only one that recognizes the client's needs and focuses on the client's feelings.
Which client behavior demonstrates denial of a sexual abuse event? 1. Pacing while mumbling profanities 2. Minimizing the severity of the event 3. Being confused about the details of the event 4. Sitting quietly and calmly reading a magazine
sitting quietly and calmly reading a magazine Rationale: Denial is a response by a victim of sexual abuse. It is described as an adaptive and protective reaction and may be identified by a calm and quiet behavior in the client. The remaining options all present some recognition that the event actually occurred. Test-Taking Strategy(ies): Focus on the subject, the behavior that demonstrates denial. Think about this defense mechanism and its description, and then read each option to direct you to the correct one.
A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client? 1. "It is very, very hard to get over these types of feelings after being raped." 2. "What do you think you should do to reduce the likelihood that you will be raped again?" 3. "Tell me more about what happened and what causes you to feel like the rape just occurred." 4. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."
tell me more about what happened and what causes you to feel like the rape just occurred Rationale: The correct option explores the client's thoughts and feelings directly and fully. At the same time, it conveys an unhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs reassurance that these feelings are normal and may be expressed in this safe care environment. Avoid any option that places the client's feelings on hold, blocks further communication, or is likely to increase the client's fear. Test-Taking Strategy(ies): Use therapeutic communication techniques. Eliminate each of the incorrect responses, knowing that the client's feelings should always be addressed.
Which is a primary behavior of a client diagnosed with antisocial personality disorder? a. Frequently expresses suicidal ideations b. Leaves the dayroom when anyone else enters c. Will take personal items from other clients' rooms d. Requires constant reassurance whenever required to make a decision
will take personal items from other client's rooms Rationale: A central defining characteristic of the antisocial personality is disregard for the rights and feelings of others. Taking the belongings of others would demonstrate this characteristic. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of antisocial personality disorder. Test-Taking Strategy(ies): Focus on the subject, behavior associated with antisocial personality disorder, and note the strategic word, primary. This will assist you in answering this question correctly. Remember that these client have a disregard for the rights and feelings of others.
The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? 1. Abnormally high blood flow to the frontal lobes 2. Atrophy of both the limbic structures and cerebellum 3. Abnormally small fissures on the surface of the brain 4. Atrophy of the lateral and/or third ventricles of the brain
atrophy of the lateral and/or third ventricles of the brain Rationale: Imaging studies of the brains of individuals with confirmed diagnoses of schizophrenia have shown the consistent atrophy of the lateral and/or third ventricles. The remaining options are not consistent with the brain structure of individuals with schizophrenia. Test-Taking Strategy(ies): Focus on the subject, diagnostic results indicating a diagnosis of schizophrenia. A specific understanding of the structural abnormalities of the brain seen in the schizophrenic client is needed to answer this question. Remember that atrophy of the lateral and/or third ventricles occurs.
A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1. "Why do you believe your roommate would steal from you?" 2. "I'll see if I can arrange for you to move in with a different roommate." 3. "Tell me more about your belief that your roommate would steal from you." 4. "I hear what you are saying, but I have no reason to believe your roommate steals."
I hear what you are saying, but I have no reason to believe your roommate steals Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Eliminate options that place the client in a defensive position by asking "why" or that in any way encourage the client's paranoid belief. Test-Taking Strategy(ies): Focus on the subject, paranoia, and use knowledge of therapeutic communication techniques to answer this question. The correct option is the one that uses therapeutic technique and does not reinforce the client's belief.
What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia? a. Their child will very likely experience difficulty in school. b. The prognosis for their child is good because he is so young. c. With medication, their child is not likely to experience relapses. d. Their child will be treated for an imbalance of the chemical dopamine.
their child will be treated for an imbalance of the chemical dopamine Rationale: The dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia. The prognosis is negatively affected when the onset of symptoms occurs during the adolescent years. Although medication compliance is a strong factor in minimizing the recurrence of relapses, it is not the only factor that has an effect. Moreover, although schizophrenia has an effect on reasoning and perception, the likelihood of experiencing difficulty in school is not certain. Test-Taking Strategy(ies): Focus on the subject, characteristics associated with schizophrenia. Thinking about the pathophysiology associated with schizophrenia will direct you to the correct option. Remember that the dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia.
Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply. 1. Assisting the client to identify and test negative cognition 2. Assisting the client to participate in the treatment process 3. Assisting the client to develop alternative thinking patterns 4. Assisting the client to rehearse new cognitive and behavioral responses 5. Assisting the client with the administration of antidepressant medications 6. Assisting the client's family to participate in group therapy on a regular basis
-Assisting the client to identify and test negative cognition -Assisting the client to participate in the treatment process -Assisting the client to develop alternative thinking patterns -Assisting the client to rehearse new cognitive and behavioral responses Rationale: The goal of cognitive-behavioral therapy is to change the way clients think and thus relieve the depressive syndrome. This is accomplished by assisting the client to identify and test negative cognition, participate in the treatment process, develop alternative thinking patterns, and rehearse new cognitive and behavioral responses. Although some clients are treated with antidepressant medications, this is not a component of cognitive-behavioral therapy. The focus of this therapy is on the client, not the family. Test-Taking Strategy(ies): Focus on the subject, as it relates to cognitive-behavioral therapy for an acutely depressed client. Recall that pharmacological therapy is not a focus. Also recall that the focus of this form of therapy is on the client, not the client's family. This will direct you to the correct options.
When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply. 1. Providing complete privacy when caring for the client 2. Admitting the client to a room near the nurses' station 3. Avoiding eye contact with the client while providing nursing care 4. Arranging for a security officer to be nearby and available but out of the client's sight 5. Closing the door to the client's room to ensure privacy when providing direct client care
-admitting the client to a room near the nurse's station -arranging for a security officer to be nearby and available but out of the client's sight Rationale: The nurse should not isolate herself or himself with a potentially violent client. The client should be placed in a room near the nurses' station and not at the distant end of a corridor. The nurse should strive to maintain eye contract with the client as a means of therapeutic communication. A security officer should be readily available and visible to the client if there is a possibility of imminent violence. The door to the client's room should remain open when giving care. Test-Taking Strategy(ies): The subject relates to safety and a client who displays violent behavior. Eliminate options 1 and 5 because they are comparable or alike. To select from the remaining options, eliminate option 3 because eye contact is a means of therapeutic communication with this client.
Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. 1. Affects males more often than females 2. Is related to abnormal melatonin metabolism 3. Usually results in debilitating symptomatology 4. Improves during the spring and summer months 5. Is a result of alterations in the available amounts of sunlight 6. A craving for carbohydrates lessens during sunnier and spring months
-is related to abnormal melatonin metabolism -improves during the spring and summer months -is a result of alterations in the available amounts of sunlight -a craving for carbohydrates lessens during sunnier and spring months Rationale: Seasonal affective disorder (SAD) is believed to be a result of impaired melatonin metabolism because of decreased exposure to sunlight. Symptomatology that includes craving for carbohydrates lessens during the sunnier spring and summer months. This disorder does not result in debilitating symptomatology. It is believed that because clinical symptoms may not dramatically affect quality of life, many clients go undiagnosed, resulting in a lack of research to support that 1 gender is more greatly affected than the other. Test-Taking Strategy(ies): Focus on the subject, the characteristics of SAD. Specific knowledge about these characteristics is needed to answer this question.
A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply. 1. The client will develop adaptive coping patterns. 2. The client will identify a realistic perception of stressors. 3. The client will cease to have negative feelings about the event. 4. The client will express and share feelings regarding the present crisis. 5. The client will identify effective coping patterns that have worked in the past.
-the client will develop adaptive coping patterns -the client will identify a realistic perception of stressors -the client will express and share feeling regarding the present crisis -the client will identify effective coping patterns that have worked in the past Rationale: The feelings of negativity related to the loss caused by the hurricane are not likely to stop; lessening with time is the only reasonable possibility. The remaining options present a positive movement toward increased self-esteem and problem solving without requiring a total shift in realistic perceptions. Test-Taking Strategy(ies): Note the strategic word, most. The words adaptive, realistic, express and share feelings, and effective identify positive and realistic goals.
The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1. "That doesn't sound like the real you talking!" 2. "I'm sure you have someone if you think hard enough." 3. "It sounds as though you are feeling all alone right now." 4. "I don't believe that, and I really don't think you do either."
It sounds as though you are feeling all alone right now Rationale: The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns. Test-Taking Strategy(ies): This question tests your knowledge of therapeutic communication techniques to assist the client in expressing feelings of loneliness. Each of the incorrect options illustrates a communication block. Remember that the nurse should address the client's feelings.
As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior? 1. An indication of the need for antidepressants 2. An inability of the client to terminate from the nurse 3. An indication of the need for additional therapy sessions 4. A normal behavior that can occur during the termination period
a normal behavior that can occur during the termination period Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include the return of symptoms, anger, withdrawal, and minimizing the relationship. The behavior that the client is experiencing is normal during the termination phase and does not necessarily indicate the need for hospitalization, additional sessions, or antidepressants. Test-Taking Strategy(ies): Focus on the subject, terminating the nurse-client relationship. Additionally, note that the remaining options are comparable or alike. These options address the need for further supervised treatment.
Which is the best therapeutic approach for the nurse to use in crisis counseling? a. Reassuring b. Passive listening c. Exploration of early life experiences d. Active, with focus on the current situation
active, with focus on the current situation Rationale: During crisis counseling, the best approach for the nurse to use is an active one, with a focus on the current situation. The remaining options would be inconsistent with the acute needs that emerge in a crisis. Passive listening would be contrary to the individual's acute stress and disorganization. Exploring the past would be insensitive to the current crisis and would be exploitative of a client in acute distress. Although reassurance may be needed, what is most important about the nurse's response in a crisis is the need for a direct focus on immediate needs. Test-Taking Strategy(ies): Note the strategic word, best. Focus on the subject, crisis counseling. Noting the words current situation will direct you to the correct option.
Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1. Weigh the client 3 times per week before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. 4. Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.
arrange for the client to receive several small meals daily, and plan to be present while the meals are being served Rationale: Offering small meals at several different times during the day may be less overwhelming for the client. Being available during the meals can add to the social atmosphere of eating. Weighing the client does not address how to increase nutritional intake. The client is experiencing poor concentration and is not likely able to benefit from a nutrition lecture. The option of reporting to the psychiatrist and consulting with the nutritionist is to some degree correct but does not present a method to increase food intake. Test-Taking Strategy(ies): Focus on the subject, poor nutritional status associated with depression. The correct option is the only choice that addresses the poor nutrition concretely and presents a method by which the client is likely to increase nutritional intake.
Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions? 1. Refuses to attend group therapy 2. Asks about how to get a will notarized 3. Argues with family members during visiting hours 4. Becomes easily agitated when roommate changes the television channel
asks about how to get a will notarized Rationale: Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite and difficulty with sleep, and a loss of interest in usual activities. The remaining options all deal with anger and "acting out" behaviors that can be associated with depression. Test-Taking Strategy(ies): Focus on the subject, the need for suicide precautions. Eliminate options that are comparable or alike such as those that deal with anger and "acting out" behaviors. Note the words refuses, argues, and agitated in the incorrect options.
Which is the primary goal of crisis intervention therapy? 1. Introduce new, effective coping methods to the client. 2. Assess the client to identify the causative stressors. 3. Establish a sustainable therapeutic nurse-client relationship. 4. Assist the client in returning to the level of precrisis functioning.
assist the client in returning to the level of precrisis functioning. Rationale: The primary goal of crisis intervention therapy is returning the client to a level of functioning that is equal to or better than that experienced precrisis. This goal is reached through strategies that include the introduction of new coping methods directed toward the stressors that contributed to the crisis. The establishment of a therapeutic nurse-client relationship is a general goal for all nursing relationships. Test-Taking Strategy(ies): Note the strategic word, primary, and focus on the subject, crisis intervention therapy. Also note that the correct option is the umbrella option; assisting the client to return to the level of precrisis functioning includes options 1, 2, and 3.
The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? a. Coffee, tea, and soda consumption should be limited. b. If the client is compliant, the relapse of symptoms will never occur. c. Psychotropic medications may cause mild cardiovascular symptoms. d. Most schizophrenic clients are able to taper off their medications eventually.
coffee, tea, and soda consumption should be limited Rationale: Caffeine can inhibit the action of psychotropic medications commonly prescribed for schizophrenia. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is a strong factor in minimizing the reoccurrence of relapses, relapse could occur. Cardiovascular symptoms are not typical side effects of psychotropic medications. Test-Taking Strategy(ies): Focus on the subject, medication therapy for the client with schizophrenia. Eliminate option B because of the closed-ended word "never." From the remaining options it is necessary to know that caffeine can inhibit the action of psychotropic medications.
What is the priority nursing action when admitting a client who has just attempted suicide? a. Ensure constant observation of the client at all times. b. Conduct a thorough mental health assessment of the client. c. Determine whether the client has ever attempted suicide previously. d. Remove all potentially dangerous articles from among the client's belongings.
ensure constant observation of the client at all times Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission. Test-Taking Strategy(ies): Note the strategic word, priority. Focus on the subject, care of the suicidal client. Although all of the options may be correct, note that the nurse is admitting the client. The priority at this time is to maintain constant observation.
Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? 1. Facilitating behavioral change 2. Promoting self-esteem in the client 3. Promoting problem solving skills in the client 4. Establishing the parameters of the relationship
establishing the parameters of the relationship Rationale: During the orientation phase of the therapeutic nurse-client relationship, 4 subjects need to be addressed. These subjects are the parameters of the relationship, the formal or informal contract, confidentiality, and termination of the relationship. Promoting problem-solving skills and self-esteem and facilitating behavioral change are subjects of the working phase of the nurse-client relationship. Test-Taking Strategy(ies): Focus on the subject, the orientation phase of the nurse-client relationship. Using principles related to this phase will assist in directing you to the correct option. Also remember that the nurse first develops a therapeutic relationship with the client.
The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1. Tearful, self-isolated 2. Affect bland, withdrawn 3. Fist clenched, pounding table, fearful 4. Temperature 98.4º F (36.8º C); respirations 18 breaths/min
fist clenched, pounding table, fearful Rationale: Anxiety signs and symptoms may take a physical form and if abnormal should be addressed as a priority for the client. A temperature of 98.4º F and respirations 18 breaths/min are normal vital signs. Tearfulness, self-isolation, a bland affect, and a withdrawn state are abnormal findings but are commonly associated with anxiety. These findings are not life threatening, although they should be monitored. Fist clenched, pounding the table, and exhibiting fear indicate a possible threat to safety of the client or others. Test-Taking Strategy(ies): Focus on the subject, a client with anxiety. Note the strategic word, priority. Recalling that client safety and the safety of others constitute the priority will direct you to the correct option.
During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 1. Apathy 2. Impaired pain perception 3. Distrust of authority figures 4. Poor verbal communication skills
impaired pain perception Rationale: Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia. Although the remaining options may be general factors affecting this client's perceptions and personal interactions, they are not related to the pain perception threshold. Test-Taking Strategy(ies): Note the strategic words, most likely. Focus on the subject, that the client denies oral pain or difficulty eating. Understanding of the brain dysfunction associated with schizophrenia and its effect on pain perception will assist you to eliminate options 1, 3, and 4.
The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction? 1. Emboli 2. Hypotension 3. Thrombophlebitis 4. Impaired wound healing
impaired wound healing Rationale: Methamphetamine abuse causes vasoconstriction, resulting commonly in poor wound healing and hypertension. Thrombophlebitis and emboli are not results of vasoconstriction and are not associated with methamphetamine. Test-Taking Strategy(ies): Focus on the subject, effects of methamphetamine on the vascular system. Specific knowledge about methamphetamine abuse is needed to answer this question. Recalling that the effect of methamphetamine is vasoconstriction will direct you to the correct option.
The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? a. Including the client's support system in the teaching b. Facilitating weekly maintenance therapy for the client c. Having the client restate discharge goals and strategies d. Stressing the importance of client compliance with the medication plan
including the client's support system in the teaching Rationale: Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective. Test-Taking Strategy(ies): Note the strategic word, primary. Focus on the subject, relapse prevention. Recalling the importance of a support system will direct you to the correct option.
Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving? 1. Increased number of hours slept at 1 time and is increasingly alert 2. Appears to be delirious but has stopped trying to pull out the nasogastric tube 3. Tells his wife, "I do feel better, but why are snakes in the corner of my room?" 4. Appears anxious whenever approached by staff but relaxes when family is present
increased number of hours slept at 1 time and is increasingly alert Rationale: The foreign environment of a hospital's critical care unit, the loss of a normal sleep-wake cycle, effects of injuries, and succumbing to placement of invasive lines, tubes, and possibly restraints can lead to delirium and feelings of powerlessness. The symptoms of psychosis are more likely to resolve when the client resumes a more normal sleep cycle and is physiologically stable. Improvement from intensive care unit (ICU) psychosis is evidenced by decreased hallucinations, anxiety, and aggressive behavior, along with increased sleep and absence of injuries. Test-Taking Strategy(ies): Focus on the subject, improvement in a client experiencing ICU psychosis. Eliminate options 2, 3, and 4 since they demonstrate some behaviors associated with this disorder.
A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1. Daily medication therapy 2. Involvement with a support group 3. Intense stress management training 4. Short exposure to the phobic object
short exposure to the phobic object Rationale: Systematic desensitization is a form of therapy in which the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, over a period of time, exposure is increased until the anxiety about or fear of the object or situation has ceased. Medication is associated with pharmacological therapy. While stress management techniques and self-help groups may be helpful, neither is the basis of this therapy. Test-Taking Strategy(ies): Focus on the subject, components of systematic desensitization. Specific knowledge regarding this form of therapy is required to answer this question. Also, thinking about the definition of desensitization will direct you to the correct option.
The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? a. Increased appetite, irritability, anxiety, restlessness, and altered concentration b. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor c. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia d. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis Rationale: Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. Option D identifies the signs and symptoms associated with opioid withdrawal. Option A describes cocaine withdrawal. Option B identifies signs associated with nicotine withdrawal. Option C describes alcohol withdrawal. Test-Taking Strategy(ies): Focus on the subject, signs and symptoms associated with opioid withdrawal. To answer this question accurately, you must be able to discriminate among symptoms that occur with withdrawal from various types of substances. Recalling the effects of opioids in the body will assist in answering correctly.
The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority? 1. Interrupt the client, and offer to take her for a walk. 2. Allow the client to complete her exercise program. 3. Ignore the behavior, and return when the client is finished. 4. Tell the client that she is not allowed to exercise rigorously.
interrupt the client, and offer to take her for a walk Rationale: When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amounts of exercise. Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of their physical state. The correct option stops the harmful strenuous exercise and provides an unharmful form of exercise. The remaining options are inappropriate priority actions. Test-Taking Strategy(ies): Note the strategic word, priority. Focus on the subject, anorexia nervosa, and use knowledge of this disorder to eliminate options that can be harmful to the client or that ignore inappropriate behaviors.
The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "It provides a negative reinforcement when the stimulus is produced."
it provides a negative reinforcement when the stimulus is produced Rationale: Aversion therapy provides a negative reinforcement when the stimulus is produced. The remaining options are characteristics of self-control therapy. Test-Taking Strategy(ies): Note the strategic words, need for further teaching, in the question. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Think about the subject, self-control; this will assist in answering correctly.
Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? 1. "My husband tells me that I'm back to my old cheerful self." 2. "My boss tells me that I'm being considered for a promotion and a raise." 3. "When I find myself getting stressed, I immediately use the relaxation techniques I've learned." 4. "I have a different perspective on life now. I'm more confident of my ability to handle any problem."
my boss tells me that I'm being considered for a promotion and a raise Rationale: The report that the client is doing well at work indicates a level of functioning amid stress that is at least equal to that of the precrisis period. Being told by her spouse that she is again cheerful is a positive improvement but is not indicative of general functioning. Being self-aware and recognizing the need to implement coping methods appropriately when stress triggers are present is a positive indicator of improvement, as is an improved sense of empowerment and confidence in handling problems, but neither indicates the true ability to successfully handle stress efficiently or the client's return to her precrisis level of functioning. Test-Taking Strategy(ies): Note the strategic words, most likely. Focus on the subject, returned to her precrisis level of functioning. Eliminate options that reflect only 1 aspect of the client's personality or that lack substantiated actions that support the client's ability to function at the precrisis level. This will assist in answering correctly.
The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1. "I am your friend." 2. "Our relationship is a therapeutic and helping one." 3. "I can't be your friend. I'm the nurse, and you're the client." 4. "You have plenty of friends. You don't need me to be your friend, too."
our relationship is a therapeutic and helping one Rationale: Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship. Test-Taking Strategy(ies): Focus on the subject, a therapeutic nurse-client relationship, and use therapeutic communication techniques to assist in answering the question. This should help direct you to the correct option.
The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? 1. Brain anomalies that are responsible for this disorder 2. Signs that indicate the client may be considering suicide 3. The importance benzodiazepines play in the management of this disorder 4. The possibility that the client will experience medication-induced tinnitus
signs that indicate the client may be considering suicide Rationale: Suicide is the most serious concern for clients with mood disorders. Early identification of behaviors that reflect the client's suicidal mind-set is vital to minimizing the risk of self-injury and/or death. Mood disorders are not typically a result of brain anomalies. Benzodiazepines are not the medication classification of choice for treating mood disorders. Tinnitus is not a typical side effect of antidepressant medication therapy. Test-Taking Strategy(ies): Focus on the subject, informational plan for the family of a client with a mood disorder. Note the strategic word, priority, in the question. Noting the word suicide in option 2 will direct you to this choice.
The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking? 1. Provide the client with written instructions regarding the routine of the unit. 2. Present verbal instructions regarding expectations in single, simple commands. 3. Assess the client's understanding of instructions by requiring restatement of expectations. 4. Incorporate family members in determining the emotional and physical needs of the client.
present verbal instructions regarding expectations in single, simple commands Rationale: A client with concrete thinking often has difficulty with multiple-step tasks and commands. The information should be provided in clear, concise, and single-focused commands to minimize client confusion and maximize understanding. The client may be incapable of processing information in written form and is not likely able to restate directions because of thought process dysfunction. These methods do not address the limitations of concrete thinking. Using family to help determine the client's needs may be an appropriate intervention, but this is not directed at minimizing the effect of the client's altered thought processes. Test-Taking Strategy(ies): Focus on the subject, interventions to manage the client's concrete thinking. Eliminate options that are dependent on the client possessing intact cognitive functioning, which is something lacking in a client exhibiting concrete thinking. Also eliminate any option that does not address the need to encourage client autonomy but rather has the family assume the responsibility.
The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care? 1. Allow the client to set the goals for the plan of care. 2. Let the client act out initially, and use the quiet room and restraints as needed. 3. Provide assistance with grooming and nutrition until the client's thinking has cleared. 4. Repeatedly point out inconsistencies in the client's communication during initial treatment.
provide assistance with grooming and nutrition until the client's thinking has cleared Rationale: In the acute phase, the nurse must assume responsibility for planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Including the client in decision making at this point is incorrect because these actions do not provide a structured routine. Repeatedly pointing out inconsistencies is a nontherapeutic communication technique. Test-Taking Strategy(ies): Focus on the subject, care for a client with acute schizophrenia. Think about the pathophysiology associated with schizophrenia and use Maslow's Hierarchy of Needs theory to answer correctly. This will direct you to option 3.
The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time? a. Providing the other clients on the unit with a sense of comfort and safety b. Providing a safe place for the client to pace that is away from the other clients c. Offering the client a less stimulated area in which to calm down and gain control d. Assisting in caring for the client in a controlled environment, such as a quiet room
providing a safe place for the client to pace that is away from the other clients Rationale: Safety for the client and other clients is the priority. The correct option is the only choice that addresses the client's and other clients' safety needs. This action also focuses on the client's need to pace and safely physically work off anxious feelings. None of the other options addresses the needs of all the clients. Test-Taking Strategy(ies): Note the strategic word, priority. Also note the data in the question. Determining the client's need to physically work off anxious feelings and recalling the need to protect all clients will direct you to the correct option.
A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time? 1. Remaining with the client 2. Teaching the client deep-breathing techniques 3. Encouraging the client to talk about her feelings 4. Putting the client in a quiet room, away from other clients
remaining with the client Rationale: A client with severe anxiety may feel abandoned and become overwhelmed if left alone. Placing the client in a quiet room is also indicated, but it is more important to stay with the client. The client may not feel comfortable being located a distance from other people. It is not realistic to teach the client deep breathing or relaxation until the anxiety decreases. Encouraging the client to share feelings would be appropriate after anxiety has decreased. Test-Taking Strategy(ies): Note the strategic words, highest priority. This tells you that more than 1 option may be partially or totally correct and that you must prioritize your answer. Focus on the subject, managing an anxious client. Eliminate options 2 and 3 first knowing that these actions are inappropriate with a severe state of anxiety. Eliminate option 4 next because of the words away from other clients. The client may not feel comfortable being located at a distance from other people.
During a group session, a client threatens to "punch every one of you." Which is the appropriate initial nursing action? 1. Call security to come to the session immediately. 2. Require the client to leave the group immediately. 3. Remind the client that punching anyone is a reason for being placed into seclusion. 4. Remind the client that talking about personal anger is appropriate, but acting on it is not.
remind the client that talking about personal anger is appropriate, but acting on it is not Rationale: If a client threatens to act out physically during a group session, the client should be told that he or she can talk about his or her anger but cannot act on it during the group session. Because the client's action was a threat, it is best for the nurse to deal with the behavior. The remaining options are not appropriate as initial reactions. Test-Taking Strategy(ies): Focus on the subject, an aggressive client, and on the strategic word, initial. Remember if a client exhibits anger, it is best to initially deal with the client's behavior by focusing on the client's feelings.
Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action? 1. Establish a centrally located mental health disaster center. 2. Ask for referrals from local health care providers and clergy. 3. Station mental health professionals at established assistance centers. 4. Distribute fliers identifying the availability of psychological counseling.
station mental health professionals at established assistance centers Rationale: It is important for victims of traumatic experiences to be quickly and effectively identified, and for services to be promptly initiated. It is best that mental health professionals proactively go to places where the victims tend to gather, assess them for early symptoms of crisis, and offer to implement the appropriate services. The remaining options are passive in nature, relying on the victims to identify themselves and their needs. Test-Taking Strategy(ies): Note the strategic words, most effective. Focus on the subject, identifying individuals experiencing difficulty coping with a disaster. Eliminate options 1, 2, and 4 because these are attempts to indirectly identify individuals in need.
A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement? 1. The charge nurse blames staff for wasting supplies. 2. The charge nurse claims that administration wasn't critical. 3. The charge nurse refuses to believe the supervisor's criticisms. 4. The charge nurse smiles and nods in agreement when reprimanded.
the charge nurse blames staff for wasting supplies Rationale: Ego defense mechanisms are operations outside of a client's awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on individuals less threatening than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-inducing events or feelings. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Test-Taking Strategy(ies): Focus on the subject, an example of displacement. Think about the definition of displacement. Remember that displacement is the discharging of pent-up feelings on individuals less threatening than those who initially aroused the emotion.
A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact? 1. The client has experienced more than 1 sexual assault. 2. The client routinely incorporates foreign objects into the sex act. 3. The client actively and commonly initiates situations in which sex is forced. 4. The client regularly reexperiences the events associated with the assault.
the client regularly reexperiences the events associated with the assault Rationale: The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and experiencing the self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has been called rape trauma syndrome, the client reexperiences the trauma, as evidenced by recurrent recollections of the event. The remaining options are not associated with rape trauma syndrome. Test-Taking Strategy(ies): Focus on the subject, rape trauma syndrome. Think about the manifestations that occur in a post-trauma event. Remembering that the client reexperiences the trauma, as evidenced by recurrent recollections of the event, will direct you to the correct option.
A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? 1. The object of the crisis 2. The client's physical condition 3. The client's coping mechanisms 4. The presence of support systems
the client's physical condition Rationale: The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed with the mental health interview that involves the remaining options. Test-Taking Strategy(ies): Note the strategic word, initial. Use Maslow's Hierarchy of Needs theory to answer the question. Physiological needs take priority over other needs. The correct option is the only one that addresses a physiological
The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning? 1. "You have to ask your psychiatrist for the pass; I can't get it for you." 2. "When your psychiatrist comes in, I will ask for a pass for the weekend." 3. "You are not ready for such a pass, and I'm sure that your psychiatrist will say no." 4. "When your psychiatrist arrives on the unit, I will let them know that you have a question."
when your psychiatrist arrives on the unit, I will let them know that you have a question Rationale: The nurse should become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In the correct option, the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary and then only as a step toward helping them act on their own. Consistently encouraging clients to use their own resources helps minimize their feelings of helplessness and dependency and also validates their potential for change. Test-Taking Strategy(ies): Focus on the subject, the appropriate nursing statement and the goal that has been set for this client to achieve an optimal level of functioning and appropriate resource utilization. Eliminate any option that is abrupt or that does not provide the client with helpful information. Eliminate options where the nurse is taking action for the client. The only option that will encourage the client to develop resources is option 4.
