MH Final Exam (#2)

D) a women's shelter

Which referral would a nurse make for a client who was badly beaten by a spouse, has no place to go, and no financial means? A) community food bank B) vocational counseling C) law enforcement D) a women's shelter

Ans:B Encourage the client to talk about his or her experience(s); be accepting and nonjudgmental of the client's accounts and perceptions. Retelling the experience can help the client to identify the reality of what has happened and help to identify and work through related feelings. Do not imply that the client is responsible for the abuse.

15. A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually abused repeatedly by her husband. Which of the following interventions would be appropriate in relation to this piece of data? A) Avoid discussing the abuse so not to upset her B)Encourage her to talk about her feeling related to the abuse C)Request an anxiolytic to reduce her anxiety levels D)Help her explore her role in perpetuating the abuse

Ans: C Warning signs of abused/neglected children include serious injuries such as fractures, burns, or lacerations with no reported history of trauma; delay in seeking treatment for a significant injury; the child or a parent giving a history inconsistent with severity of injury; inconsistencies or changes in the child's history during the evaluation by either the child or the adult; unusual injuries for the child's age and level of development, such as a fractured femur in a 2-month-old or a dislocated shoulder in a 2-year-old; high incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of the rectum or vagina; and evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that the parent/caregiver cannot explain adequately.

16. The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur. Which of the following data obtained during the assessment would raise the nurse's suspicion that the child has suffered physical abuse? A) The parents appearing overprotective of the child B) Bruises over the child's bony prominences C) The injury occurring several days before the parents sought treatment D) Both parents reporting the exact same details pertaining to the injurious event

Ans: A In the emergency setting, the nurse is an essential part of the team in providing emotional support to the victim. The nurse should allow the woman to proceed at her own pace and not rush her through any interview or examination procedures. Giving back to the victim as much control as possible is important. Ways to do so include allowing her to make decisions, when possible, about whom to call, what to do next, what she would like done, and so on.

17. A woman has just presented at the emergency department after being raped. The initial nursing action would be to A) provide emotional support. B) refer her to a rape crisis hotline. C) encourage her to file charges immediately. D) perform a nursing history and physical as quickly as possible.

Ans: D Many of the examination procedures, such as a pelvic exam, may cause the woman to feel violated again. The client needs emotional support and evidence collection as well as physical care. It would not be appropriate for the nurse to make decisions for this client.

18. The nurse is working in the emergency department with a woman who was raped 1 hour ago. Which of the following is most important for the nurse to remember when planning care? A) The client should set aside any angry feelings until physical care is completed. B) Evidence collection according to procedures is not as important as treating the client's injuries. C) The nurse will need to make decisions for this client. D) The woman may feel threatened by some of the procedures.

Ans: C Feedback: Warning signs of relationship violence include gets jealous for no reason; tells you with whom you may be friends or how you should dress, or tries to control other elements of your life; does not view you as an equal: sees himself as smarter or socially superior; is angry or threatening to the point that you have changed your life or yourself so you would not anger him.

21. The nurse at a university health services clinic has been asked to meet with a freshman class of women about warning signs of relationship violence. The nurse points out which of the following danger signs the students should be alert for in a date? A) Dislikes your fiends B) Acts indifferent to your life choices C) Is excessively jealous D) Views you as superior to himself

Ans: D Feedback: In tension building, the abuser attempts to establish complete control over all the person's actions. It is more appropriate for the nurse to listen to the client, rather than to judge whether the client is overreacting. This may or may not require a restraining order. The student's boyfriend is insecure and needs reassurance, but that is not the only concern.

23. A female college student comes to the counseling center and tells the nurse she is afraid of her boyfriend. She states, ìHe is so jealous and overprotective; he wants to know where I am and who I'm with every minute.î Which of the following is most likely true of the situation? A) The student is overreacting. B) This is a situation requiring a restraining order. C) The student's boyfriend is simply insecure and needs reassurance. D) This is characteristic of the tension-building phase of the violence cycle

Ans: D Feedback: Statistics indicate that violence increases when the victim attempts to leave or end the relationship. It is not appropriate for the nurse to offer advice such as this. It is not the victim's fault whether the victim stays or not. ìIf you leave, maybe he'll see that he has to change his behavior,î is not appropriate as it minimizes the situation.

23. The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, ìWhat do you think about that?î Which is the best response by the nurse? A) ìBatterers never change, so it would be best for you to leave.î B) ìIf you don't leave, he'll think you're going to continue to endure his abuse.î C) ìIf you leave, maybe he'll see that he has to change his behavior.î D) ìYou may be in more physical danger after you leave him.î

Ans: A Feedback: Nurses may believe that a woman who stays in an abusive relationship might deserve or enjoy the abuse or that abuse between husband and wife is private. The nurse may also feel horror or revulsion. Because clients often watch for the nurse's reaction, containing these feelings and focusing on the client's needs are important. The nurse must be prepared to listen to the client's story, no matter how disturbing, and support and validate the client's feelings with comments such as ìThat must have been terrifyingî or ìSounds like you were afraid for your life.î The nurse must remember that he or she cannot fix or change things; the nurse's role is to listen and convey acceptance and support for the client.

25. A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a woman would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which of the following approaches? A) Keeping focused on the client's feelings about her life situation B) Honestly asking the client why she repeats the cycles of victimization C) Convincing the client to develop a self-rescue plan D) Not prying into the details of the client's private life

C) physical injuries

A client has not been to work in three days. When she returns to work, she is wearing dark glasses. Facial and body bruises are visible. Her supervisor takes her to the occupational nurse. Which assessment is the priority for the nurse? A) coping mechanisms B) emotional distress C) physical injuries D) psychological trauma

C) emotional abuse

A community health nurse visits a home and finds a child who stayed home from school to care for a younger sibling. The nurse observes that the house is cluttered and dirty. When asked about the parents, the child states he does not think his father likes him because he calls him "stupid." The nurse suspects which type of abuse? A) physical abuse B) sexual abuse C) emotional abuse D) economic abuse

11. The nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize which of the following? A) Decreased problem-solving ability B) Restlessness and irritability C) Remorse D) Severe muscle tension

Ans: B Feedback: Earliest signs of anger include restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger. Escalated signs include pale or flushed face, yelling, swearing, agitation, threatening, demanding, increased muscle tension such as clenched fists, threatening gestures, hostility, and loss of ability to solve the problem or think clearly. Remorse is seen after the anger crisis when attempts are made at reconciliation.

22. The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? A) Client's mood B) Client's safety C) Court order D) Physician's order

Ans: B Feedback: The use of restraints is warranted only when the client's safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base her decision on the client's mood or court order. Just because there is a physician's order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.

C) honeymoon stage

The client tells the nurse that her husband abuses her often with he drinks, just as his father had beaten him and his mother. He always apologizes and is remorseful after the event. Which stage is this in the cycle of violence? A) tension building stage B) acute battering stage C) honeymoon stage D) recovery stage

Which of the following statements regarding the individual responses to trauma and stressors is a positive outcome? A) Many individuals are unable to cope with the event, manage their stress and emotions, or resume the daily activities of their lives. B) Some individuals may develop enhanced coping as a result of dealing with the stressor. C) These events are only significant in individuals who have risk for or actual mental health problems or issues. D) Large numbers or groups of people may be affected by a traumatic event.

B

10. The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting? A) Triggering B) Escalation C) Crisis D) Recovery

Ans: B Feedback: During the escalation phase of aggression, a person may exhibit yelling and threatening, clenched fist, threatening gestures. During the triggering phase of aggression, a person may exhibit signs and symptoms and behaviors including restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger.

Ans: A If the client is injured, she may need immediate medical attention; if she is in a safe place, she can talk to the nurse on the phone. All other questions can wait until the client's safety is ensured.

19. A young woman telephones the emergency department and loudly tells the nurse, ìI've been raped! Please help me!î Which of the following is the priority for the nurse to determine? A) If the client was in a safe place, her condition, and if transportation is available B) If the client knew her assailant, knew her location, and had notified the police C) If the client has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility D) If the client had bathed, douched, or changed clothes

Ans: A, D, E One characteristic of violent families is social isolation. Members of these families keep to themselves and usually do not invite others into the home or tell them what is happening. If the client reports that the father was abusive during childhood, that would support the suspicion that the client is a victim of abuse. The abusive family member almost always holds a position of power and control over the victim. The abuser exerts not only physical power but also economic and social control. Substance abuse, especially alcoholism, has been associated with family violence.

1. The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply. A) The client has few friends. B) The client holds a dominant role in the family. C) The client is in charge of the family finances. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.

7. Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn. Which is stage V of Kubler-Ross's stages of grieving? A) Denial B) Bargaining C) Acceptance D) Anger

Ans: C Feedback: Acceptance occurs when the person shows evidence of coming to terms with death. Denial is shock and disbelief regarding the loss. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. Anger may be expressed toward God, relatives, friends, or health-care providers.

Ans: C Intimate partner violence is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. The relationship may be spousal, between partners, boyfriend, girlfriend, or an estranged relationship. Ninety to ninety- five percent of domestic violence victims are women. By deduction, this means that 5% to 10% of domestic violence victims are men. The abuse can be emotional or psychological, physical, sexual, or a combination (which is common). All abuse is harmful.

10. The client is talking to the nurse about her intimate relationships. Which one of the following statements regarding intimate partner violence is true? A) Males are never the victim in intimate partner violence. B) It is common for abusers to use one type of abuse only. C) Intimate partner violence can exist with former partners. D) Psychological abuse is not as harmful as physical abuse.

Ans: A Sixty-four percent of child maltreatment victims suffered neglect; 16% were physically abused; 8.8% were sexually abused; 6.6% were psychologically or emotionally abused; and 2.2% were medically neglected. Also, 15% suffered ìotherî types of maltreatment such as abandonment, physical threats, and congenital drug addiction.

11. The nurse is involved in a community education program for new parents and plans to include information on child abuse. The nurse will teach the parents that the most common form of child abuse is which of the following? A) Neglect B) Physical abuse C) Sexual abuse D) Emotional abuse

Ans: D Elders are often reluctant to report abuse, even when they can, because the abuse usually involves family members whom the elder wishes to protect. Victims also often fear losing their support and being moved to an institution.

12. A coherent elderly woman has been financially and emotionally abused by her adult children for the past several years, but has failed to report the abuse to anyone. Which is the most likely reason that the woman neglects to report the abuse? A) She cannot claim abuse if there is no evidence of physical harm. B) Laws do not provide protection against abuse when the suspect(s) is/are family members. C) She has no financial resources to hire legal representation against her children. D) She is emotionally close to her children and does not want to bring them harm.

Ans: A Only 20% of rapes are committed by strangers. A phenomenon called date rape (acquaintance rape) may occur on a first date, on a ride home from a party, or when the two people have known each other for some time. It is more prevalent near college and university campuses. The highest incidence is in girls and women 16 to 24 years of age. Rape most commonly occurs in a woman's neighborhood, often inside or near her home. Most rapes are premeditated.

13. A school nurse is educating a group of adolescent girls about rape and sexual assault. The nurse evaluates the students' understanding when they report which of the following as a high-risk factor regarding the incidence of rape? A) The highest incidence of rape occurs in adolescents and young adult women. B) Most rapes are committed by strangers. C) Most rapes are random acts of violence. D) A victim is at highest risk in unfamiliar neighborhoods.

Ans: A, B, C, E One third of abusive men are likely to have come from violent homes. Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. Dependency on the abuser is a common trait found in victims of domestic violence. The victim may believe that he or she caused the abuse, but this is not accurate. It is critical for the nurse to demonstrate acceptance after hearing about the abuse so that the victim may begin to gain self-acceptance.

14. Which of the following are common behavioral and emotional responses to abuse? Select all that apply. A) One third of abusive men are likely to have come from violent homes. B) Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. C) Dependency on the abuser is a common trait found in victims of domestic violence. D) The victim caused the abuse. E) It is critical for the nurse to demonstrate acceptance after hearing about the abuse so that the victim may begin to gain self-acceptance

1. A nurse is working with a client who has frequent angry outbursts. Which of the following statements is most helpful when working with this client? A) ìAnger is a normal feeling, and you can use it to solve problems.î B) ìYou need to learn to suppress your angry feelings.î C) ìYou can reduce your anger by hitting a punching bag.î D) ìYou need to learn how to be less assertive in your communications.î

Ans: A Feedback: Anger can be a normal and healthy reaction when situations or circumstances are unfair or unjust, personal rights are not respected, or realistic expectations are not met. If the person can express his or her anger assertively, problem solving or conflict resolution is possible. Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. A person may deny or suppress (i.e., hold in) angry feelings if he or she is uncomfortable expressing anger. Catharsis can increase rather than alleviate angry feelings. Effective methods of anger expression, such as using assertive communication, to express anger should replace angry aggressive outbursts.

Ans: B Battered immigrant women face legal, social, and economic problems different from US citizens who are battered and from people of other cultural, racial, and ethnic origins who are not battered: The battered woman may come from a culture that accepts domestic violence. She may believe she has less access to legal and social services than do US citizens. If she is not a citizen, she may be forced to leave the United States if she seeks legal sanctions against her husband or attempts to leave him. She is isolated by cultural dynamics that do not permit her to leave her husband; economically, she may be unable to gather the resources to leave, work, or go to school. Language barriers may interfere with her ability to call 911, learn about her rights or legal options, and obtain shelter, financial assistance, or food. The nurse must treat the whole person and encourage the client to share the details in order to protect the client's safety and well- being.

2. A young female immigrant presents in the rural health clinic with facial bruising and a fractured nose. The client is reluctant to give details of the nature of her injuries. Which of the following should be a consideration in providing care for this client? A) Most views regarding domestic violence are universal across cultures. B) She may fear deportation if she seeks public assistance. C) Immigrants have expedited access to public legal services. D) The nurse should ignore the details and focus on treatment.

Ans: C Feedback: In some instances, the parent feels the need to have children to replace his or her own faulty and disappointing childhood; the parent wants to feel the love between child and parent that he or she missed as a child. The reality of the tremendous emotional, physical, and financial demands that comes with raising children usually shatters these unrealistic expectations. When the parent's unrealistic expectations are not met, abuse often follows. Having a support system and a sense of discipline can contribute to effective parenting. Financial worries may be a concern, but relying on a baby to meet emotional needs is a high-risk dynamic for child abuse

20. The nurse is discussing expectations of raising a child with a pregnant teenager expecting her first baby. The father will not be a participant in the parenting. Which of the following statements made by the expectant mother would be of greatest concern to the nurse? A) ìI am going to rely on my sisters for a lot of help raising my baby.î B) ìI was raised with very strict discipline.î C) ìMy child will love me unlike my parents ever did.î D) ìI am not sure how I am going to pay for all the things my child will need.î

Ans: A Feedback: The nurse should not assume the bruises were caused by abuse; the client's explanation is an important step in the assessment of potential abuse. A nurse must assess for abuse prior to getting the supervisor and physician involved. Reporting abuse would be initiated after a thorough assessment

24. The nurse is assessing an elderly female in the emergency department. There are many bruises present on her body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next? A) Ask the client when and how the bruises occurred B) Call the nursing supervisor immediately C) Follow the facility's policy and procedures for reporting abuse D) Notify the physician that abuse is suspected

Ans: A, C, D, B Feedback: The tension-building phase begins; there may be arguments, stony silence, or complaints from the husband. The tension ends in another violent episode after which the abuser once again feels regret and remorse and promises to change. This cycle continually repeats itself. Each time, the victim keeps hoping the violence will stop.

26. The school nurse is teaching a health class about recognizing the signs of abusive relationships. The nurse describes the cycle of violence. The nurse would document effective teaching if the students identify the cycle of violence to be which of the following patterns? Select the order in which the events occur. A. Tension building B. Honeymoon period C. Violent behavior D. Period of remorse

Ans: D Feedback: Elder abuse may develop gradually as the burden of care exceeds the caregiver's physical or emotional resources. Relieving the caregiver's stress and providing additional resources may help to correct the abusive situation and keep the caregiving relationship intact.

27. The community health nurse meets with the family members of an elderly client. The nurse includes which of the following in the plan of care as a preventive measure to guard against elder abuse? A) Reassure the primary caregiver that he or she in the best position to provide care to the elder B) Teach the primary caregiver skills to meet all of the elder's needs C) Assist in the transfer of legal authority for elder care to the primary caregiver D) Provide the primary caregiver with additional resources to meet the elder's needs

6. Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder

Ans: A, B, D Feedback: Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggressive behavior also is seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders.

25. The nurse is establishing outcomes for a grieving client. Which of the following is an appropriate outcome? A) The client will develop a plan for coping with the loss. B) The client will demonstrate self-reliance during the grief process. C) The client will suppress emotions related to the loss. D) The client will verbalize that loss will not adversely affect the quality of life.

Ans: A Feedback: Examples of outcomes for the grieving client are as follows: - Identify the effects of his or her loss. - Identify the meaning of his or her loss. - Seek adequate support while expressing grief. - Develop a plan for coping with the loss. - Apply effective coping strategies while expressing and assimilating all dimensions of human response to loss in his or her life. - Recognize the negative effects of the loss on his or her life. - Seek or accept professional assistance if needed to promote the grieving process.

13. A client approaches the nurse and loudly states, ìI'm not putting up with this anymore!î The most appropriate response by the nurse would be which of the following? A) ìI can see you are angry. Tell me what's going on.î B) ìYou are not allowed to make threats. Please keep your voice down.î C) ìWhy do you say that?î D) ìYou are here voluntarily. You can leave if you want.î

Ans: A Feedback: In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. Conveying empathy for the client's anger or frustration is important. The nurse can encourage the client to express his or her angry feelings verbally, suggesting that the client is still in control and can maintain that control. Use of clear, simple, short statements is helpful.

Ans: B The intergenerational transmission process shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning. Not all persons exposed to family violence, however, become abusive or violent as adults.

3. Which of the following is the best explanation for why family violence tends to occur over multiple generations of families? A) A tendency toward violence is hereditary. B) Family violence may be perpetuated between generations of families by role modeling and social learning. C) All persons who have become victims of family violence will grow up to perpetrate family violence. D) Family violence does not tend to have an intergenerational transmission process.

Ans: A, B, C, D Research studies have identified some common characteristics of violent families regardless of the type of abuse that exists. They include social isolation, abuse of power and control, alcohol and other drug abuse, intergenerational transmission. The victim does not instigate abuse.

4. Which of the following are common characteristics of violent families regardless of the type of abuse that exists? Select all that apply. A) Abuse of power and control B) Alcohol and other drug abuse C) Intergenerational transmission D) Social isolation E) Victim instigates

Ans: A, B, D, E Dependency is the trait most commonly found in abused wives who stay with their husbands. Women often cite personal and financial dependency as a reason why they find leaving an abusive relationship extremely difficult. The victim may suffer from low self-esteem and defines her success as a person by her ability to remain loyal to her marriage and ìmake it work.î Some women internalize the criticism they receive and mistakenly believe they are to blame. Women also fear their abuser will kill them if they try to leave. An abuser often has feelings of low self-esteem and poor problem-solving and social skills and may interpret any attempts at defense or any behavior of the abused person as abuse of the perpetrator.

5. Which of the following are common reasons why abused women remain with the abusive partner? Select all that apply. A) The abused person is personally and financially dependent on the abuser. B) The abused person has low self-esteem and defines her success as a person by the ability to make the relationship work. C) The abused person is convinced that she has been abusive toward the abuser at some point and that the abuse is her fault. D) The abused person believes that she is unable to function without her husband. E) The abused person is afraid that the abuser will kill her if she tries to leave.

Ans: A, B, C The perpetrator often believes that the partner is his own property. The perpetrator is often irrationally jealous, even of his own children if the partner pays any attention to them. The perpetrator is emotionally immature and needy. The perpetrator does not respect his partner because if he did, he would not believe that the partner is his own property to do with as he wishes. The perpetrator wants to maintain control over his partner and is therefore not intimidated by the partner but by the thought of the partner not being available.

6. Which of the following are typical characteristics of the perpetrator of intimate partner abuse? Select all that apply. A) The perpetrator often believes that the partner is his own property. B) The perpetrator is often irrationally jealous, even of his own children. C) The perpetrator is emotionally immature and needy. D) The perpetrator respects his partner. E) The perpetrator is intimidated by his partner.

Ans: A Nightmares and flashbacks are common in people who were abused as children regardless of their current age. The client may have ill effects irrespective of the age. The client will likely have low self-esteem. The client will likely have difficulty relating to anyone, including the nurse.

7. The nurse is caring for a 16-year-old boy with a history of sexual abuse. What might the nurse expect to assess with this client? A) The client will experience long-term emotional trauma. B) The client will have no ill effects due to his age. C) The client will have high self-esteem. D) The client will easily share his concerns with the nurse.

Ans: C Children who have sexual knowledge not expected at their age have often been sexually abused. A child who has been sexually abused by an adult may feel more comfortable with peers than with adults. Learning problems, shyness, and wearing dirty and threadbare clothing may be related to many situations other than sexual abuse.

8. Which of the following behaviors would first alert the school nurse or teacher to suspect sexual abuse in a 7-year-old child? A) The child has a preference for associating with peers, rather than adults. B) The child has learning problems and shyness. C) The child tells sexually explicit stories to peers. D) The child wears dirty and threadbare clothing

Ans: C An abusive husband often believes his wife belongs to him (like property) and becomes increasingly violent and abusive if she shows any sign of independence, such as getting a job or threatening to leave. Typically, the abuser has strong feelings of inadequacy and low self-esteem as well as poor problem-solving and social skills. He is emotionally immature, needy, irrationally jealous, and possessive. By bullying and physically punishing the family, the abuser often experiences a sense of power and control. Therefore, the violent behavior often is rewarding and boosts his self-esteem. A typical pattern of abuse exists: Usually, the initial episode of battering or violence is followed by a period of the abuser expressing regret, apologizing, and promising it will never happen again.

9. Which characteristic of the abuser should the nurse look for when completing the family assessment of a victim on intimate partner violence? A) Encourages the partner to have a life outside the intimate relationship B) An inflated sense of self-esteem C) Needy and possessive of the partner D) An ability to feel remorse for the abuse

B) physical abuse

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

10. The nurse is working with a client who lost her youngest child 2 months ago. When the nurse approaches, the client, the client yells, "I don't want to talk to you. You have no idea what it's like to lose a child!" The nurse bases her response to the client on the understanding of which of the following? A) Hostility is a common behavioral response to grief. B) It is too soon after the loss to empathize with the client. C) Personality traits such as aggressiveness are exaggerated during the grief process. D) The nurse may have nonverbally indicated a judgmental attitude toward the client.

Ans: A Feedback: Behavioral responses to grief are often the easiest to observe. Irritability and hostility toward others reveal anger and frustration in the grief process.

8. Friends of a teenage male recently killed in a car accident are discussing their sense of loss. Which of the following comments best indicates that the friends are trying to make sense of the loss cognitively? A) "Why did he have to die so young?" B) "He shouldn't have been driving so recklessly." C) "If we had only stayed longer, he would not have been on that road." D) "It took the ambulance too long to get there."

Ans: A Feedback: One of the cognitive responses to grief involves the grieving person making sense of the loss. He or she undergoes self-examination and questions accepted ways of thinking. The loss challenges old assumptions about life. Anger, sadness, and anxiety are the predominant emotional responses to loss. The grieving person may direct anger and resentment toward the dead person and his or her health practices, family members, or health-care providers or institutions.

16. An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following? A) Call for an emergency response from trained personnel. B) Approach the client and firmly say, ìStop, put it down.î C) Calmly call the client by name and encourage verbal expression of anger. D) Assist the client to use problem-solving techniques instead of aggression.

Ans: A Feedback: When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physically aggressive client. Verbal expression and problem solving are ineffective once a client has reached the crisis phase. The priority is to maintain safety and regain control.

19. When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first? A) Call for assistance. B) Give the client choices. C) Remove the other clients. D) Talk to the client calmly.

Ans: A Feedback: Safety is the priority; the nurse needs assistance to remove other clients and to deal with the violent outburst. The other interventions may be implemented after calling for assistance.

30. One of the first steps that a nurse should take to deal effectively with aggressive clients is which of the following? A) Reflect on abilities to handle own feelings of anger B) Learn professional skills of anger management C) Become proficient using reflective communication techniques D) Understand how to activate crisis response teams

Ans: A Feedback: The nurse must be aware of how he or she deals with anger before helping clients do so. The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to ìtalk downî the client's anger. Identifying how you handle angry feelings is an initial task. Once the nurse understands his or her own experiences with anger, the clients can be helped through learning the use of assertive communication and conflict resolution. Increasing your skills in dealing with your angry feelings will help you to work more effectively with clients. Activating a crisis response is a late option in dealing with anger.

11. Which of the following are eventual outcomes of the emotional dimension of grieving? Select all that apply. A) The survivor begins to reestablish a sense of personal identity, direction, and purpose for living. B) The survivor begins to gain independence and confidence. C) The survivor develops new ways of managing life and new relationships. D) The survivor's life returns to the same state as it was before the loss. E) The survivor forgets about the loss.

Ans: A, B, C Feedback: Eventually, the bereaved person begins to reestablish a sense of personal identity, direction, and purpose for living. He or she gains independence and confidence. New ways of managing life emerge and new relationships form. The person's life is reorganized and seems "normal" again, although different than that before the loss. The person still misses the deceased, but thinking of him or her no longer evokes painful feelings.

26. Which of the following interventions are most effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. A) Planning group activities such as playing games B) Scheduling one-to-one interactions with the client C) Providing structure and consistency in the unit D) Avoiding discussions among clients on the unit E) Discouraging clients from negotiating solutions

Ans: A, B, C Feedback: Group and planned activities such as playing card games, watching and discussing movies, or participating in informal discussions give the clients the opportunity to talk about events or issues when they are calm. Scheduling one-to-one interactions with clients indicates the nurse's genuine interest in the client and a willingness to listen to the client's concerns, thoughts, and feelings. Knowing what to expect enhances the client's feelings of security. Avoiding discussions does not give clients the opportunity to talk about events or issues when they are calm. If clients have a conflict or dispute with one another, the nurse can offer the opportunity for problem solving or conflict resolution. Expressing angry feelings appropriately, using assertive communication statements, and negotiating a solution are important skills clients can practice. These skills will be useful for the client when he or she returns to the community.

19. Which of the following persons are most likely experiencing complicated grieving? Select all that apply. A) The spouse of a person who died 7 years ago and visits the grave several times a day. B) The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day. C) A driver whose spouse and children all died as a result of his driving drunk. D) An adult who insisted for many years that he or she hated his or her deceased parent. E) The parent of a child who died after the having left the child in a car on a hot day.

Ans: A, C, D, E Feedback: The spouse of a person who died 7 years ago and visits the grave several times a day is likely experiencing complicated grieving as this is a prolonged period of time with expression of grief that is exaggerated. A driver whose spouse and children all died as a result of his driving drunk likely experiences feelings of guilt as well as loss. An adult who insisted for many years that he or she hated his or her deceased parent is likely experiencing complicated grief as he or she has experienced an ambivalent attachment. The parent of a child who died after having left the child in a car on a hot day is likely experiencing guilt as well as loss.

2. Which of the following statements about anger, hostility and aggression are accurate? Select all that apply. A) Anger is an emotional response to a real or perceived provocation. B) Hostility stimulates the sympathetic nervous system. C) Physical aggression involves harming other persons or property. D) Anger, hostility, and physical aggression are normal human emotions. E) Hostility is also referred to as verbal aggression. F) Physical aggression often progresses to hostility.

Ans: A, C, E Feedback: Anger is an emotional response to a real or perceived provocation. Anger energizes the body physically for self-defense, when needed, by activating the ìfight-or-flightî response mechanism of the sympathetic nervous system. Hostility is different than anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property. Hostility is also referred to as verbal aggression. Anger is a normal human emotion. Hostility is an emotion that is expressed through negative behavior. Physical aggression is behavior. Hostility may lead to physical aggression.

13. The nurse is caring for a hospice client whose death is imminent. In preparing the family for the death of their loved one, then nurse prepares to assist the family in which of the following, regardless of the family's cultural preferences? Select all that apply. A) Dealing with the shock of losing a loved one B) Burial plans after death had occurred C) Efforts to stay connected to the client after death D) Use of support from family and friends E) Anger at the loss of a loved one

Ans: A, C, E Feedback: Universal reactions include the initial response of shock and social disorientation, attempts to continue a relationship with the deceased, anger with those perceived as responsible for the death, and a time for mourning. Not all cultures bury their deceased. Some cultures mourn privately, not turning to the support of others.

30. Which of the following are critical components in assessment of a person's grief? Select all that apply. A) Adequate perception regarding the loss B) Adequate time to experience the loss C) Adequate support while grieving for the loss D) Adequate opportunities to say goodbye to the person E) Adequate coping behaviors during the process

Ans: A, C, E Feedback: While observing for client responses in the dimensions of grieving, the nurse explores three critical components in assessment: • Adequate perception regarding the loss • Adequate support while grieving for the loss • Adequate coping behaviors during the process The time to experience the loss varies significantly from person to person, and the reality is that there may not be adequate opportunities to say goodbye to the person.

32. Which of the following are important issues for nurses to be aware of when working with angry, hostile, or aggressive clients? Select all that apply. A) Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution. B) Nurses must not allow themselves to become angry under any circumstances. C) Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse. D) Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.

Ans: A, D, E Feedback: Nurses must identify how they handle angry feelings and assess their use of assertive communication and conflict resolution. Increasing their skills in dealing with their angry feelings will help the nurses to work more effectively with the client. Nurses must not take the client's anger or aggressive behavior personally or as a measure of their effectiveness as a nurse. Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior

33. A client is scheduled for a mastectomy for breast cancer. She is quiet, shows little emotion, and states that she has no questions. The nurse's assessment would need to focus on A) the client's plans for reconstructive surgery. B) the meaning of the mastectomy to the client. C) whether the client truly understands the surgery. D) why the client seems depressed.

Ans: B Feedback: Assessment begins with exploration of the client's perception of the loss. A client who is scheduled for a mastectomy would possibly be having anticipatory loss of a physiologic nature. It would not be appropriate to discuss the client's plans for reconstructive surgery as this is not likely what is causing the client to be quiet and show little emotion. It is important to ascertain whether the client truly understands the surgery when witnessing the client's signature of the operative consent, but there is no indication that this is what is being addressed at this time. It would not be appropriate to assume that the client is depressed or not. It would be better to explore the client's perception of the loss.

20. The nurse is meeting a client for the first time who has just spontaneously lost her unborn child. After establishing rapport, the priority nursing intervention should focus on which of the following? A) Assessing the client's support system B) Exploring what this loss means for the client C) Discussing helpful ways to cope with the loss D) Assessing what knowledge the client desires about the situation

Ans: B Feedback: Assessment begins with exploration of the client's perception of the loss. What does the loss mean to the client? The question is valuable for beginning to facilitate the grief process. Further assessment and intervention will be determined based largely on the client's perception of the event.

9. A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggressing cycle? A) Triggering B) Escalation C) Crisis D) Recovery

Ans: B Feedback: During escalation, the client's responses represent escalating behaviors that indicate movement toward a loss of control, including pale or flushed face, yelling, swearing, agitated, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly. This phase is followed by the crisis phase. During a period of emotional and physical crisis, the client loses control. Behaviors may include loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, and inability to communicate clearly.

18. The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance

Ans: B Feedback: Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression.

15. In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression? A) Getting as far away from him or her as possible B) Engaging the hostile person in dialogue C) Yelling at the client to settle down now D) Ensuring that the client gets his or her way

Ans: B Feedback: In a psychiatric setting, engaging the hostile person is most effective to prevent the behavior from escalating to physical aggression. In the psychiatric setting, it is not possible to get as far away from them as possible. Yelling at the client will likely escalate the hostility. Ensuring that the client gets his or her way may eliminate frustration that may lead to acting out, but is unrealistic and not ultimately helpful to the client.

21. The client identifies anger management as a problem. What is the next step in planning therapeutic interactions? A) Give the client a variety of choices on how to express anger. B) Give the client permission to be angry. C) Point out the senselessness of anger. D) Tell the client not to be angry all the time.

Ans: B Feedback: Many people view anger as a negative and abnormal feeling in addition to feeling guilty about being angry; the nurse can help the client see anger as a normal, acceptable emotion. Giving choices on how to express anger would not be the next step in the planning stage. Pointing out the senselessness of anger and telling the client not to be angry all the time are not appropriate responses in this situation.

8. Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? A) Delusions B) Depression C) Dementia D) Delirium

Ans: B Feedback: Some clients with depression have anger attacks that are sudden intense spells of anger that typically occur in situation where the depressed person feels emotionally trapped. Anger attacks involve verbal expressions of anger or rage but no physical aggression. Persons with delusions, dementia, and delirium are most likely to become physically aggressive.

12. The nurse is conducting a history and physical exam on a client who is grieving the unwanted loss of a marriage by divorce. Which of the following physical symptoms of grief would the nurse most likely expect to detect in the history? A) Headaches B) Insomnia C) Weight loss D) GI upset

Ans: B Feedback: Those grieving may complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the immune and endocrine systems. Sleep disturbances are among the most frequent and persistent bereavement-associated symptoms.

1. A young couple just ended their relationship after a 9-month engagement. The one of the individuals is seeking short-term counseling to assist in grieving this loss. Which type of loss best describes what this client is experiencing? A) Safety loss B) Loss of security and sense of belonging C) Loss of self-esteem D) Loss related to self-actualization

Ans: B Feedback: Types of loss include safety loss (loss of a safe environment), loss of security and a sense of belonging (loss of a loved one affects the need to love and the feeling of being loved), loss of self-esteem (any change in how a person is valued at work or in relationships or by him or herself), or loss related to self-actualization (external or internal crisis that blocks or inhibits strivings toward fulfillment).

24. Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others

Ans: B Feedback: Verbally expressing angry feelings is a safe and appropriate way to deal with anger. Isolation and catharsis can increase angry and hostile feelings. The other choices are not appropriate responses in this situation.

7. Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects

Ans: B Feedback: Clients with psychiatric disorders are more likely to hurt themselves than other people.

21. Which of the following are critical components to assess in a grieving person? Select all that apply. A) Genetic risk B) Perception of the loss C) Support system D) Coping behaviors E) Religion

Ans: B, C, D Feedback: The interaction of the dimensions of human response is fluid and dynamic. What a person thinks about during grieving affects his or her feelings, and those feelings influence his or her behavior. The critical factors of perception, support, and coping are interrelated as well and provide a framework for assessing and assisting the client. Genetic risk and religion are not critical components to assess in a grieving person.

17. Which of the following losses are likely to result in disenfranchised grief? Select all that apply. A) A young adult whose spouse has just died suddenly B) A family whose long-time pet snake has just died C) A nurse who has just witnessed the death of a patient D) A couple who has just experienced pregnancy loss E) The gay lover of a man who just died from AIDS F) The mother and sister of a soldier who was killed in war

Ans: B, C, D, E Feedback: Circumstances that can result in disenfranchised grief include a relationship that has no legitimacy, the loss itself is not recognized, the griever is not recognized, or the loss involves social stigma. A young adult whose spouse has just died suddenly is not likely to experience disenfranchised grief because of their legal relationship. A family whose long-time pet snake had died is likely to experience disenfranchised grief because the death of a pet is not seen as socially significant. A nurse who had just witnessed the death of a patient is at risk for disenfranchised grief because the needs of nurses and hospital chaplains are not recognized. A couple who had just experienced a pregnancy loss are at increased risk for disenfranchised grief because the loss of an unborn child is not recognized. The gay lover of a man who just died from AIDS is at risk for disenfranchised grief as the relationship had no legitimacy and the loss involves social stigma. The mother and sister of a soldier who was killed in war would not likely experience disenfranchised grief because they have a kin relationship with the decedent.

28. After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the client at this time? A) ìWe will have to talk about this later.î B) ìYou really scared me. I'm glad you are okay.î C) ìWhat happened that got you so upset?î D) ìWhat can you do differently next time you get angry?î

Ans: C Feedback: As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. Talking about the event at a later time does let the client rest, but it does less to address the client's feelings associated with the angry outburst. It is too early postcrisis to discuss behavior change for the future as the client needs to recover from intense emotions first.

3. Which of the following terms is used to describe the process by which a person experiences the grief? A) Anticipatory grieving B) Disenfranchised grief C) Bereavement D) Mourning

Ans: C Feedback: Bereavement refers to the process by which a person experiences the grief. Anticipatory grieving is when people facing imminent loss begin to grapple with the very real possibility of the loss or death in the near future. Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Mourning is the outward expression of grief.

33. What a culture considers acceptable strongly influences the expression of anger. Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects? A) Hwa-Byung B) Hwabyeong C) Amok D) BouffÈe delirante

Ans: C Feedback: BouffÈe delirante, a condition observed in West Africa and Haiti, is characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. Hwa-Byung or hwabyeong is a culture-bound syndrome that literally translates as anger syndrome, or fire illness, attributed to the suppression of anger. Amok is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects.

6. The client says to the nurse, "I really want to see my first grandchild born before I die. Is that too much to ask?" The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Acceptance B) Anger C) Bargaining D) Depression

Ans: C Feedback: Clients often set goals such as living until a certain time or to experience a particular event, and then they will be ready to die: that is the bargain. Acceptance occurs when the person shows evidence of coming to terms with death. Anger may be expressed toward God, relatives, friends, or health-care providers. Depression results when awareness of the loss becomes acute.

23. A young client tells the nurse that her husband died 3 months ago, and she is feeling alone and vulnerable. Which statement by the client would indicate that her coping skills are adequate? A) "I can't understand why this happened to me." B) "I'm mentally healthy. I can solve my own problems." C) "I will find a support group." D) "What can I do? My husband abandoned me."

Ans: C Feedback: Finding a support group indicates that the client recognizes her need for help and is taking action to get the support she needs. The other choices are not indications that the client's coping skills are adequate for the situation.

14. A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time? A) Clear others out of the immediate area. B) Prepare a PRN sedative. C) Tell the client to stop and take a time-out. D) Alert the security department of an impending aggressive outburst.

Ans: C Feedback: If the client progresses to the escalation phase (period when client builds toward loss of control), the nurse must take control of the situation. The nurse should provide directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or his or her room. Clearing others from the area or alerting security does not help the client regain control. Administering a sedative is not the least restrictive intervention at this time.

5. At which point in the stages of aggressive incidents is intervention least likely to be effective in preventing physically aggressive behavior? A) Triggering B) Escalation C) Crisis D) Postcrisis

Ans: C Feedback: Interventions during the triggering and escalation phases are key to prevent physically aggressive behavior. During the crisis phase, behavior escalation may lead to physical aggression. During the postcrisis phase, the physically aggressive behavior has stopped and the client returns to the level of functioning before the aggressive incident.

26. The nurse approaches a client who looks very sad and is sitting alone crying. The best response by the nurse in this situation is, A) "I'm sorry you are sad. Is there anything I can do to help you feel better?" B) "Please don't cry. It will get better." C) "You look very sad. What is happening?" D) "What is bothering you?"

Ans: C Feedback: It is essential to accept the person's feelings without trying to dissuade him or her from feeling angry or upset. The nurse needs to encourage the person to express any and all feelings without trying to calm or placate him or her.

4. A married couple has just received the news that the husband has terminal cancer. The wife tells the nurse, "Maybe if we get another opinion and start treatment right way there is a chance of survival." The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? A) Denial B) Anger C) Bargaining D) Depression

Ans: C Feedback: Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn: (1) Denial is shock and disbelief regarding the loss. (2) Anger may be expressed toward God, relatives, friends, or health-care providers. (3) Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. (4) Depression results when awareness of the loss becomes acute. (5) Acceptance occurs when the person shows evidence of coming to terms with death.

18. Which of the following is most likely to prevent the client from experiencing complicated grief? A) Tendency to suppress emotions B) History of depression C) Places trusts familiar others D) Dependent on others to meet needs

Ans: C Feedback: People who are vulnerable to complicated grieving include those with low self-esteem, low trust in others, a previous psychiatric disorder, previous suicide threats or attempts, or absent or unhelpful family members.

14. The most effective way for the nurse to provide culturally competent care to individuals who are grieving is which of the following? A) Understand the practices associated with a client's culture. B) Suggest developing a new ritual to make mourning meaningful. C) Ask the client what rituals are personally meaningful. D) Contact a spiritual leader from the client's culture to become involved.

Ans: C Feedback: Rather than assuming that he or she understands a particular culture's grieving behaviors, the nurse must encourage clients to discover and use what is effective and meaningful to them.

3. A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively? A) ìI really wish you would stop nagging me.î B) ìYou are not perfect either.î C) ìI feel unappreciated when you criticize me.î D) ìAre you telling me you want me to change?î

Ans: C Feedback: The nurse can help clients express anger appropriately by serving as a model and by role-playing assertive communication techniques. Assertive communication uses ìIî statements that express feelings and are specific to the situation; for example, ìI feel angry when you interrupt me,î or ìI am angry that you changed the work schedule without talking to me.î Statements such as these allow appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger.

28. An elderly woman who lives alone is beginning to have difficulty maintaining her household and performing daily tasks. The nurse asks her to identify someone who can help her. The woman replies, "I don't need help. I've been managing for years." Which of the following responses helps the client shift from denial to consciously coping with her situation? A) "You don't think you need any help? But your family is worried about you." B) "It must be hard to lose your independence. I'll ask a social worker to see what can be arranged." C) "If you were to need help with your house, who might you ask for help?" D) "If you don't ask for some help. then the only option is to move to an assisted living facility."

Ans: C Feedback: The nurse can help the client to reach out and accept what others want to give in support of his or her grieving process. Help the client shift from an unconscious mechanism of denial to conscious coping with reality by using reflective communication skills. Do not force people through the coping process by insisting they take certain actions.

31. A client comes to the physician's office for an annual checkup. During the interview, the nurse learns that the client's husband died unexpectedly of a heart attack 2 months ago. The most appropriate response by the nurse would be, A) "At least you and your husband enjoyed life right until the end." B) "It's better to go quickly like your husband did instead of suffering." C) "The loss of your husband must be very painful for you." D) "You'll feel better after you get over the shock of your husband's death."

Ans: C Feedback: The nurse makes an empathetic response, acknowledging the client's loss. "At least you and your husband enjoyed life right until the end," is judgmental. "It's better to go quickly like your husband did instead of suffering," does not address the client's grief. "You'll feel better after you get over the shock of your husband's death," is false reassurance. Thus, choices A, B, and D would not be the most appropriate responses.

20. The client with a history of explosive outbursts becomes angry and states, ìI am really getting angry.î The nurse sees this as A) controlling. B) manipulation. C) progress. D) regression

Ans: C Feedback: When the client is able to verbalize angry feelings, this is progress from having an outburst. The client is not trying to control the situation. Manipulation occurs when a person tries to persuade another to act in a desired way. Regression occurs when one retreats to an earlier level of functioning and development.

17. A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.

Ans: C Feedback: Following an aggressive episode, clients may have difficulty expressing themselves; short, concise statements and questions will get needed information. Humor or open- ended questions may be frustrating or annoying for the client. It is not safe for the nurse to provide close contact under these circumstances.

27. A woman has just been served divorce papers from her husband. She has no financial resources and little social support. She states, "He's not really leaving. He'll be back." The most appropriate response by the nurse would be which of the following? A) "Has he done this before?" B) "I'll call social services and get you signed up for financial assistance." C) "You have to face reality. Here are the papers." D) "How is this affecting you right now?"

Ans: D Feedback: Adaptive denial, in which the client gradually adjusts to the reality of the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. While taking in the loss in its entirety all at once seems overwhelming, gradually dealing with the loss in smaller increments seems much more manageable. Help the client shift from an unconscious mechanism of denial to conscious coping with reality by using reflective communication skills.

9. The nurse is working with a woman who lost her partner nearly 3 weeks prior. The woman has recently become less emotional and expressed that few things in her life have meaning right now. Which response by the nurse is most appropriate at this time? A) "I am concerned. You are starting to show signs of ineffective grieving." B) "You must feel some anger. It is alright to let that out." C) "Let's look at the things in your life that you still enjoy." D) "You are just starting to accept that this loss is real."

Ans: D Feedback: As the bereaved person begins to understand the loss's permanence, he or she recognizes that patterns of thinking, feeling, and acting attached to life with the deceased must change. As the person relinquishes all hope of recovering the lost one, he or she inevitably experiences moments of depression, apathy, or despair. The acute sharp pain initially experienced with the loss becomes less intense and less frequent.

22. A client with terminal cancer has been told he has 3 or 4 months to live. Which of the following would indicate to the nurse that further interventions are needed? A) The client says he wants to live life to the fullest. B) The client hopes for a peaceful and dignified death. C) The client is reviewing his life and talking about death. D) The client says he is well and is making future plans.

Ans: D Feedback: Choice D would indicate that the client is proceeding as though there is no impending loss, so the nurse would need to assist the client with grieving as the client is in denial. The other choices are positive coping behaviors toward death.

16. A woman has just had a therapeutic abortion to end an unintended pregnancy. Afterward, the woman cries because although she wanted to have children in future years, this pregnancy was not well-timed. Which type of grief is this woman most likely to experience? A) Anticipatory grief B) Absence of grief C) Complicated grief D) Disenfranchised grief

Ans: D Feedback: Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned, publicly, or supported socially. Anticipatory grief occurs when a person experiences imminent loss and begin to grapple with the very real possibility of loss or death in the near future. It is not absence of grief as the woman is grieving. It is not currently complicated grief as the loss has just occurred and does not seem out of proportion to the loss.

31. Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger

Ans: D Feedback: Do not take the client's anger or aggressive behavior personally or as a measure of your effectiveness as a nurse. The client's aggressive behavior, however, does not necessarily reflect the nurse's skills and abilities. Clients should not dictate nurses' behaviors. The nurse is not responsible for angering the client. Individuals are responsible for their own emotional control. If the nurse cannot maintain boundaries, assistance should be sought form a supervisor.

23. The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse? A) Take an authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what is going on. D) Engage the attention of the client who is still yelling and ask what is happening.

Ans: D Feedback: Engaging the attention of the dominant person will diffuse the situation and stop the argument from continuing. The other choices would not be appropriate actions in this situation. The nurse placing herself in between two arguing clients is a safety concern.

27. Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain

Ans: D Feedback: Four to six trained staff members are needed to restrain, with four staff members each handling a limb and one protecting the client's head and one helps control the client's torso, if needed. When a client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Only staff with training in safe techniques for managing behavioral emergencies should participate. All staff may not have had this training, and if the team is not working in a cooperative and coordinated fashion, it is less safe to restrain the client. The nurse should follow the facility's protocols and standards for restraint and seclusion. Staff should inform the client that his or her behavior is out of control and that the staff is taking control to provide safety and prevent injury.

24. A couple came to the emergency department with their 5-month-old son. He was pronounced dead of sudden infant death syndrome (SIDS). In the next day or two, it will be important for this couple to A) accept that they could do nothing to prevent this death. B) delay the grieving process until they are ready to cope. C) minimize their discussion of the death with others. D) plan funeral arrangements for their son.

Ans: D Feedback: Funerals are often the beginning outward sign of mourning and help begin the grieving process. This couple will need to talk about their son's death repeatedly as they begin to grieve. It will not likely be possible for them to accept that they could do nothing to prevent this death within this time period, but they must begin to hear this. They should not delay the grieving process.

29. After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? A) ìYou still need to work on your problem-solving skills.î B) ìI will not allow you to get that angry again.' C) ìYou should not have let your anger buildup like you did.î D) ìWhat could you have done when you first started to feel angry?î

Ans: D Feedback: In the postcrisis phase, the nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future.

15. A nurse has been caring for a gunshot victim who has just died. Various family and friends are present. One of the visitors privately discloses to the nurse that she and the client were having an illicit affair. Which of the following is the best action by the nurse after learning of this relationship? A) Give the name of a clergy to the visitor and suggest she contact him for support B) Encourage the visitor to ask for support from the friends who are present C) Ignore the information about the affair and tend to the family D) Privately offer support to the visitor who was having the affair with the client

Ans: D Feedback: Relationships between lovers, friends, neighbors, foster parents, colleagues, and caregivers may be long-lasting and intense, but people suffering loss in these relationships may not be able to mourn publicly with the social support and recognition given to family members. In addition, some relationships are not always recognized publicly or sanctioned socially such as extramarital affairs. The grief process is more complex because the usual supports that facilitate grieving and healing are absent. Therefore, nurses should be mindful to provide needed support.

2. A child who has witnessed the murder of his classmate while at school would experience which kind of loss? A) Physiologic loss B) Loss of self-esteem C) Loss related to self-actualization D) Safety loss

Ans: D Feedback: Safety loss is the loss of a safe environment. That feeling of safety is shattered when public violence occurs. Examples of physiologic loss include amputation of a limb, a mastectomy or hysterectomy, or loss of mobility. A loss of self-esteem includes any change in how a person is valued at work or in relationships or by himself or herself can threaten self-esteem. Loss related to self-actualization includes an external or internal crisis that blocks or inhibits strivings toward fulfillment that may threaten personal goals and individual potential.

29. A client who has been grieving the loss of his wife 2 weeks ago says to the nurse, "The best part of my day is when I am back at work. Is that wrong?" The nurse educates that work and other daily activities serve which purpose? A) "You cannot work effectively this soon. You should finish grieving first." B) "Working reminds you of your loss. It may be too early to go back." C) "Working is your way of avoiding grief, which will make it harder for you to move on." D) "Working is letting you take an emotional break from grieving. There's nothing wrong with that."

Ans: D Feedback: The bereaved person can often take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide that respite. Familiar routines can affirm the client's talents and abilities and can renew feelings of self-worth.

5. After being laid off from work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt, and is eating and sleeping poorly. The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Anger B) Bargaining C) Denial D) Depression

Ans: D Feedback: The client's symptoms are characteristics of depression, which usually occurs when awareness of the loss becomes acute. Anger may be expressed toward God, relatives, friends, or health-care providers. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. Denial is shock and disbelief regarding the loss.

32. A woman has just delivered a stillborn baby boy. Which of the following would be the most appropriate nursing response? A) "Can I do anything for you?" B) "If something was wrong, it's better this way." C) "Your son is in heaven with God now." D) "Would you like to hold your son?"

Ans: D Feedback: The opportunity to hold the baby may help the woman deal with the first stage of grieving: denial; it also allows her to express emotions over the loss. Asking the client, "Can I do anything for you," is a closed-ended question and will likely be replied to with a yes or no answer. Stating, "If something was wrong, it's better this way," is not sensitive to the woman's loss. Stating "Your son is in heaven with God now," would be inappropriate because it may not be consistent with the woman's beliefs.

25. A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client? A) ìThe length of time you'll be in restraints is undetermined.î B) ìThe staff will monitor your behavior closely.î C) ìThis is what happens when you lose control.î D) ìThis is a means of keeping you and others safe.î

Ans: D Feedback: Use of restraints is a temporary, short-term way of ensuring the safety of everyone until the client regains behavioral control; it is not a punishment. The other choices are not appropriate explanations of the use of restraints.

4. Which one of the following statements about anger is most accurate? A) Anger is an abnormal human emotion that is always negative. B) It is best to express anger by whatever means possible to minimize its consequences. C) Most men are socialized to suppress anger. D) Anger awareness and expression are necessary for women's growth and development.

Ans: D Feedback: Women must recognize that anger awareness and expression are necessary for their growth and development. Anger is a normal human emotion and is often perceived as a negative feeling. However, anger becomes negative when denied, suppressed, or expressed inappropriately. Anger that is expressed inappropriately can lead to hostility and aggression. Catharsis can increase rather than alleviate angry feelings. Men are often socialized to believe that it is acceptable to express anger, while women are often socialized to maintain and enhance relationships with others and avoid expression of emotions such as anger.

12. A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse? A) ìI can see that you need attention; you should calmly ask for what you want.î B) ìI don't want to hear that kind of language; don't ever do that again.î C) ìI will limit your smoking privileges if you can't control yourself.î D) ìYou seem angry. Tell me more about how you're feeling.î

Ans: D Feedback: The nurse recognizes and validates the client's feelings and offers to focus on those feelings and what the client needs. In this situation, the client is not at a point where he can be calm. Taking away privileges will not help the current situation. ìI don't want to hear that kind of language; don't ever do that againî is demeaning to the client.

What is the major difference between posttraumatic stress disorder (PTSD) and acute stress disorder? A) In acute stress disorder, the client is likely to develop exacerbation of symptoms. B) In PTSD, the recovery rate is 80% within 3 months. C) The severity and duration of the trauma are the most important variables in acute stress disorder. D) In PTSD, the symptoms occur 3 months or more after the trauma.

D