222 wk4 ATI questions

A client wants to know about relaxation techniques. What does the nurse say to educate the client? A. Relaxation techniques work best when they are practiced on a regular basis B. heart rate should be specifically monitored while relaxing C. The technique should not be used in children D. To avoid dependence, only practice relaxation techniques when absolutely necessary

A

A nurse assesses severe anxiety in a client. Which symptoms would the nurse expect to see as a response of the sympathetic nervous system to anxiety? A. Tachycardia B. Bradycardia C. Constricted pupils D. Increased peristalsis

A

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assess the clients risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

A

A nurse is teaching a client about stress-reduction techniques. Which of the following statements indicates understanding of the teaching? A. Cognitive reframing will help me change my irrational thoughts to something positive B. Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate C. Biofeedback causes my body to release endorphins so that I feel less stress and anxiety D. Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety

A

Lorazepam is prescribed for a client who has generalized anxiety disorder. Which of the following instructions is most important for the nurse to give the client? A. Prolonged use can result in dependence B. Take the medication 2 hours after eating C. Take an additional dose if you dont obtain relief. D. Return once a month to have your blood level tested

A

What would a client experience during a progressive relaxation session? A. Instruction in sequential tensing and relaxing of various muscle groups until the entire body is relaxed B. Being attached to a machine that monitors a physical parameter and receiving audible feedback about the state of that parameter C. Having a nurse enter the client's energy field to rebalance it and bring harmony D. Being led into a positive imaginary sensory experience

A

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. I will administer prophylactic treatment for sexually transmitted infections, like chlamydia B. I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence C.I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder D. I should use narrative documentation when documenting subjective data

A Incorrect B - Obtain informed consent to collect data for legal evidence C - Similar to PTSD D -Document subjective data using clients verbatim statements

A nurse is caring for an adult client who has injuries resulting from spousal abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority A. Advise the client about the location of safe houses and shelters B. Encourage the client to participate in a support group for survivors of abuse C. Implement case management to coordinate community and social services D. Educate client about the use of stress management techniques

A Incorrect B,C,D - Not priority

A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. Tell me about how you are feeling right now B. You should focus on the positive things in your life to decrease your anxiety C. Why do you believe you are experiencing this anxiety D. Lets discuss medications your provider is prescribing to decrease your anxiety

A - Asking open ended questions

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? A. Excessive stressors cause the client to experience distress B. The body's initial adaptive response to stress is denial C. Absence of stressors results in homeostasis D. Negative, rather than positive, stressors produce a biological response

A - Distress is result of excessive or damaging stressors Incorrect B - Denial is part of grief process, initial response is fight or flight C - Individuals need presence of some stressors to provide interest and purpose to life D - Both positive and negative stressors produce biological response in body

Stress reduction is likely to result in which of the following? (SATA) A. Reduced pain B. Lower blood pressure C. Decreased cognitive functions D. Decreased gastrointestinal problems E. Terminal insomnia

A,B,D

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (SATA) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbance

A,D,E B - Characterized by procrastination in decision making C - Muscle tension not delayed reflexes

A client is experiencing sudden, moderate-level anxiety. The nurse would anticipate that the psychiatrist would most likely prescribe which medication? A. Citalopram B. Alprazolam C. Fluoxetine D. Chlordiazepoxide

B

A client with chronic ongoing stress complains of physical symptoms. The nurse caring for him is aware that the most common chronic problem by stress is which of the following? A. Nausea B. Headaches C. Chest Pain D. Depressed mood

B

A nurse is caring for a 23 year old client with schizophrenia. When the patients father shows up during visitation hours, the client lies down in bed, curls up in ball, and sucks his thumb. Which of the following defense mechanism is the client exhibiting? A. Undoing B. Regression C. Altruism D. Displacement

B

A nurse observe a male client who is hyperactive and intrusive sitting very close to a female client with his arm around her shoulders. The nurse hears the male client tell a sexually explicit joke. The nurse approaches the client and asks him to walk down the hallway. Which statement by the nurse should benefit the client? A. She will not want to be around you with that kind of talk B. Telling sexual jokes and touching others is not permitted here C. You need to be careful about what you say to other people D. I think a time-out in your room would be appropriate now

B

A patient nervously says, "Financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off." The patients pulse is 112/minute; respirations are 26/min and BP is 166/88. Which nursing intervention will the nurse implement? A. Advise the patient, "Go to sleep 30 to 60 minutes earlier each night to increase rest." B. Direct the patient in slow and deep breathing via use of a positive, repeated word C. Suggest the patient consider that a new job might be better than the present one D. Tell the patient, "Relax by spending more time playing with your pet."

B

The nurse assess a client to be at risk for self-mutilation and implements a safety contract with the client which client behavior indicates that the contract is working? A. The client withdraws to his room where his feelings are overwhelmed B. The client notifies staff when anxiety is increasing C. The client suppresses his feeling when angry D. The client displaces his feelings onto the HCP

B

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate of 30/min and says "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety" A. Mild B. Moderate C. Severe D. Panic

B Incorrect A - Mild, patient is able to understand info, may actually increase C - Severe anxiety causes restlessness, decreased perception, and inability to take direction D - during panic attack persons is completely distracted, unable to function, may lose touch with reality

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have a cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

B Incorrect A - reaction formation is demonstrating opposite behavior of what is felt C - Displacement is shifting feelings from one thing to another D - sublimation is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the clients situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

B Incorrect A,C,D - Does not promote change

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. Rape is a crime of passion B. Acquaintance rape often involves alcohol C. Young adults are the typical victims of sexual assault D. The majority of rapists are unknown to their victims

B - Alcohol or other substances are associated with date or acquaintance rape Incorrect A -Rape is crime of violence, aggression, anger, and power C - All ages are affected D - Majority are known to victims

A nurse is working in an emergency department is caring for a client who has benzodiazepine toxicity. Which of the following actions is the nurses priority? A. Administer flumazenil B. Identify clients level of orientation C. Infuse IV fluids D. Prepare client for gastric lavage

B - Assess patient first, ADPIE

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events as an example of client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

B - Marriage is example of maturational crisis, which is naturally occurring event during life span Incorrect A - Rape is an adventitious crisis C - Situational crisis D - Situational crisis

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (SATA) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

B - antidepressant E - Lorazepam Incorrect A - Mood stabilizer C - Antipsychotic D - Antipsychotic E - Benzodiazepine

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (SATA) A. sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increased in head circumference

B,C,D,E Incorrect A - Bulging rather than sunken are expected

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (SATA) A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

B,C,E Incorrect A - Chronic pain indicates prolonged stress D - Panic attacks indicated prolonged stress

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (SATA) A. Reassure the client that everything will be okay B. Discuss prior using the coping mechanisms with the client C. Ignore the clients anxiety so that she will not be embarrassed D. Demonstrate a calm manner while using simple and clear directions E. Gather information from the client using close-ended questions

B,D Incorrect A- Providing false reassurance is an example of nontherapeutic C- Recognize clients level of anxiety assists client to begin problem solving E - Open ended questions to allow client to express feelings and identify source

A nurse working in an emergency department is assessing a preschool age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (SATA) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

B,E Incorrect A - Minor injuries on arms and legs are common C - Mismatched clothing is consistent with clients need for independence at age D - Abdominal rebound tenderness is possible indication of appendicitis rather than abuse

A 32-year-old male client is experiencing severe anxiety over a recent failed relationship. What nursing intervention should be given highest priority? A. Give the client an antianxiety agent immediately B. Offer him psychotherapy to calm him down C. Take the client to a quiet environment D. Place him in supervised seclusion immediately

C

A client presents in the ER after being sexually assaulted. She is physiologically stable, but emotionally distraught. Which nursing action should receive priority? A. Assist with medical treatment B. Collect and prepare evidence for the police C. Attempt to reduce the clients anxiety level D. Provide anticipatory guidance about normal responses to sexual assault

C

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C

During an initial interview with parents, a nurse suspects child abuse. What behavior displayed by the parents would lead the nurse to be suspicious? A. Guilt B. Apathy C. Overconcern D. Ignoring the child

C

What is a nurse's responsibility when a child is suspected of being abused or neglected? A. Report to CPS with a physician's order B. Parents must be informed before reporting to CPS C. Reporting of suspected abuse or neglect is required by law in each state D. The nurse should consult a social worker before reporting to any authority

C

A nurse is caring for a client who was recently sexually assaulted. The client states "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. Your actions had nothing to do with what happened B. You should focus on recovery rather than blaming yourself for what happened C. You believe this wouldn't have happened if you hadn't been out alone? D. Why do you feel that you should not have been alone on the street at night?

C Incorrect A - Nurses opinion B - Indicates disapproval D - Why question

A nurse is caring or a client who is to being taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication? A. I will take this medication at bedtime B. I will follow a low-sodium diet while taking this medication C. I will need to discontinue this medication slowly D. I will be at risk for weight loss with long-term use of this medication

C Incorrect A - Taken in the morning to minimize sleep disruptions B - risk for hyponatremia when taking fluioxetine D - Risk for weight gain not weight loss

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. Children older than 5 are at a greater risk for abuse B. Substance use disorder does not increase the risk for violance C. Entering an intimate relationship increases risk for violence D. Pregnancy increases the risk for violence from a spouse or partner

D

A nurse is closely monitoring a newly admitted client who is anxious. At what anxiety level might this client become assaultive and a potential threat to himself and others? A. Mild B. Moderate C. Severe D. Panic

D

Ed, an 18 year old male, hosted a party at his parents house while his parents were out of town,. It was lit, to say the least. When Ed's parents returned, they were infuriated by how messy the house was. Ed apologized, and gave them a 50$ gift care to applebee's. Which defense mechanism is Ed using? A. Regression B. Altruism C. Reaction Formation D. Undoing

D

The client is laughing and telling jokes to a group of clients. Suddenly the client is crying and talking about a death in the family. a moment later, the client is laughing and joking again. The nurse should: A. Call the healthcare provider for a prescription for lorazepam as needed B. Place the client in seclusion and call the HCP for a prescription for the seclusion C. Ignore the client's behavior in order to not give the client too much attention D. Ask the client to come to a quiet area to talk to the nurse individually

D

What is the most appropriate therapeutic intervention when helping a patient resolve their agoraphobia? A. Having the client go outdoors alone B. Advise the client to high intensity exercises C. Allow the client to stay in his room as long as directed D. Discuss the clients fear of his/her feelings or sensations rather than the situation

D

Which intervention is least appropriate for a nurse to use with a rape victim? A. never leave the woman alone B. Encourage expression of feelings C. Emphasize that she did the right thing in order to save her life D. Allow the client to shower and brush her teeth before an examination

D

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behavior C. Distract the client with a television show D. Stay with the client and remain quiet

D Incorrect A,B,C - Clients unable to concentrate during panic attack

A nurse caring for a client who states "I am so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A. you really should complete your own work. I dont think its right to expect me to complete your responsibilities B. Why do you expect me to finish your work? You must realize that I have my own responsibilities C. It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor D. When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities

D - Assertive communication, allows client to state feelings about behavior then promote change Incorrect A - example of approving/ disapproving B - uses a why question C - Aggressive and threatening, can prompt defense reaction

A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide? A. Three to six weeks of treatment is required to achieve therapeutic benefit B. Combining alcohol with alprazolam will produce a paradoxical response C. Alprazolam has a lower risk for dependence than other antianxiety medications D. Report confusion as a potential indication of toxicity

D - Confusion is potential indication of alprazolam toxicity Incorrect A - Buspirone not alprazolam B - Can produce CNS and respiratory depression not paradoxical C - Alprazolam is used for short term treatment due to risk for independence

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (SATA) A. Genitourinary soreness B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

D,E A - Somatic reaction B - emotional response C - Somatic reaction