Med-Surg Nclex Questions

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Which statement indicates an understanding of the focus of milieu therapy?

"A living, learning, or working environment is the focus of milieu therapy."

What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety?

"I can see that you are becoming upset."

The registered nurse (RN) is listening to a lecture on pulmonary edema. Which statement by the RN indicates that the teaching has been effective? ID: 1056 | Adult Health_Cardio Questions_final.htm #1097

"The client will experience extreme anxiety."

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? ID: 4403 | Mental Health Questions_final.htm #856

"You're feeling angry that your family continues to hope for you to be cured?"

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply.

1.Timing 2.Volume 3.Voice tone 6.Ability to share thoughts and feelings

Which client is at greatest risk for committing suicide?

A client with metastatic cancer

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? ID: 1758 | Adult Health_Musculoskeletal Questions_final.htm #2139

A normal response that indicates the presence of phantom limb sensation

A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? ID: 1786 | Adult Health_Musculoskeletal Questions_final.htm #2167

A social worker

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? ID: 0805 | 65.xml #805

A structured program of activities in which the client can participate

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? ID: 0130 | 15.xml #130

"Can you share with me what you've been told about your surgery?"

A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic?

"Do you believe that there are other forms of abuse besides the physical kind?"

The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?

"It is a difficult situation, but do you agree that enabling creates codependency?"

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? ID: 2362 | Adult Health_Respiratory Questions_final.htm #2859

"The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. ID: 2185 | Adult Health_Renal Questions_final.htm #2678

1.Acknowledge the client's feelings. 2.Assess the client and family's coping patterns. 3.Explore the meaning of the illness with the client. 5.Give the client information when the client is ready to listen.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? ID: 3884 | Leadership-Management_Ethical-Legal_final.htm #858

Contact the client's primary health care provider (PHCP).

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? ID: 4418 | Mental Health Questions_final.htm #875

Conversion disorder

Which is the best therapeutic approach for the nurse to use in crisis counseling?

Active, with focus on the current situation

Which is the primary goal of crisis intervention therapy?

Assist the client in returning to the level of precrisis functioning.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? ID: 1102 | Adult Health_Endocrine Questions_final.htm #549

Convey empathy, trust, and respect toward the client.

A woman has just been told by the primary health care provider that she has breast cancer. The woman responds, "Oh, no! Does this mean I'm going to die?" The nurse interprets the woman's initial reaction as which response? ID: 2089 | Adult Health_Oncology Questions_final.htm #2569

Fear

The nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. What developmental characteristic of this child should the nurse consider? ID: 3008 | Developmental Stages_Infancy to Adolescence_final.htm #3341

Fears of mutilation may be present in the child.

A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion?

Gathering subjective and objective assessment from the caregiver and the client

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? ID: 1970 | Adult Health_Neuro Questions_final.htm #2383

Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action?

Observing rigid rules and regulations

The client tells the nurse that she cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis?

Obsessive-compulsive disorder

A client is withdrawn, immobile and mute. Which appropriate action should the nurse take?

Occasionally ask open-ended questions.

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? ID: 2853 | Developmental Stages_End of Life Care_final.htm #3221

Provide a well-lighted room.

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client?

Risk for self-harm

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? ID: 0694 | 56.xml #694

Speak at a normal volume.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and a cherished autographed picture of a performer.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? ID: 0828 | 67.xml #828

The death of a loved one

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? ID: 3256 | Fundamentals of Care_Infection Control_final.htm #3448ID: 3256 | Fundamentals of Care_Infection Control_final.htm #3448

The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

Which intervention demonstrates responsibility for the milieu in an inpatient psychiatric setting?

The nurse managing an aggressive client

During a support group session, a client says, "My husband hit me a lot, but when he threatened to start hitting our kids, I stabbed him. No jury will believe me because my husband can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse?

"Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what she's feeling?"

Which statement by the nurse indicates a need for further teaching concerning family violence?

"Abusers are more often from low-income families."

The nurse is caring for a terminally ill client who is unresponsive to verbal stimuli. The client's spouse asks if her husband can still hear her. Which is the best response by the nurse? ID: 2855 | Developmental Stages_End of Life Care_final.htm #3223

"Assume that your husband can still hear you."

The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability? ID: 3637 | Fundamentals of Care_Perioperative Care_final.htm #3909

"Can you share with me any concerns about how this surgery will affect you in the future?"

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk?

"Do you have a plan to commit suicide?"

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value?

"Do you recall what it was like before you started your medication?"

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? ID: 1893 | Adult Health_Neuro Questions_final.htm #2306

"Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure."

A female client with carcinoma of the breast is admitted to the hospital for treatment with intravenously administered doxorubicin. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. What is the most appropriate nursing response?

"Hair loss may occur, and it will grow back, but it may have a different color or texture."

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem? ID: 1364 | Adult Health_GI Questions_final.htm #1521

"Have you enjoyed having visitors?"

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response?

"Have you shared your concerns with the police?"

When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question?

"How do you feel when you haven't had a drink all day?"

The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? ID: 2767 | Culture-Spirituality Questions_final.htm #7

"I cannot have any food containing or prepared with blood."

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time?

"I don't hear them, but it must be frightening to hear voices that others can't hear."

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?

"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate should indicate to the nurse that there is a need for further teaching? ID: 3904 | Leadership-Management_Ethical-Legal_final.htm #4119

"I don't think you need to do that."

The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis?

"I exercise 3 to 4 hours every day to keep my slim figure."

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

"I hear what you are saying, but I have no reason to believe your roommate steals."

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder?

"I keep reliving the abuse."

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age? ID: 2973 | Developmental Stages_Infancy to Adolescence_final.htm #459

"I know it hurts to die."

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion?

"I know that I won't become depressed again as long as I reduce my stressors."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? ID: 4428 | Mental Health Questions_final.htm #885

"I no longer feel that I deserve the beatings my husband inflicts on me." Test-Taking Strategy(ies):Focus on the subject, the therapeutic effect of attending an Al-Anon group. Noting the words benefiting from attending an Al-Anon group will direct you to the correct option.Color Key:Cyan = Strategy Rationale:Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.Client Needs: Psychosocial IntegrityCognitive Ability: EvaluatingContent Area: Mental HealthHealth Problem: Mental Health: AddictionsIntegrated Process: Nursing Process/EvaluationPriority Concepts: Addiction, Family DynamicsStrategy(ies): Subject

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? ID: 4016 | Maternity_Antepartum_final.htm #4197

"I want to gain only 10 pounds because I want to have a small, petite baby."

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement?

"I will take the medicine until I am sure I can handle my own problems."

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety?

"It must be frightening to think that others want to hurt you."

A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response?

"It must be hard to accept that she has passed away."

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"It provides a negative reinforcement when the stimulus is produced."

A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make?

"It seems that you needed Bobby's help to separate from your family."

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind?

"It sounds as though you are feeling all alone right now."

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse will best address the daughter's concerns?

"It sounds as though you are very concerned. Let's discuss the procedure."

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy?

"It uses negative reinforcement."

A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? ID: 1130 | Adult Health_Endocrine Questions_final.htm #1240

"Let me go over the types of insulins with you again."

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse?

"Let's have a cup of coffee, and you can tell me about your father."

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother? ID: 0407 | 40.xml #407

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The primary health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning?

"My boss tells me that I'm being considered for a promotion and a raise."

A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

Minoxidil is prescribed for a client to treat hair loss. The client asks the nurse if the hair will continue to grow when the medication is stopped. What is the appropriate nursing response?

"Newly gained hair is lost in 3 to 4 months."

An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic?

"Not any 1 strategy for remaining sober is best for everyone."

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?

"Our relationship is a therapeutic and helping one."

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? ID: 0193 | 20.xml #193

"Please share with me more about your concerns."

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? ID: 2279 | Adult Health_Reproductive Questions_final.htm #243

"Please share with me more about your concerns."

A client receives education regarding self-administration of enoxaparin on discharge to home. The client complains, "I feel as if the primary health care provider is discharging me too soon if I still have to take injections at home." Which response should the nurse make?

"Research shows that it is best for clients to administer this medication at home rather than stay in the hospital."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?

"Tell me more about the incident that causes you to feel like the rape just occurred."

A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client?

"Tell me more about what happened and what causes you to feel like the rape just occurred."

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. The client expresses concern about performing this procedure at home. What is the nurse's best response? ID: 3577 | Fundamentals of Care_Nutrition_final.htm #3872

"Tell me more about your concerns about going home."

The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic?

"Tell me what makes you feel that you are ready."

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? ID: 1955 | Adult Health_Neuro Questions_final.htm #2368

"This is not a stroke, and many clients recover in 3 to 5 weeks."

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response? ID: 2860 | Developmental Stages_End of Life Care_final.htm #3228

"This must be very hard for you."

A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic?

"We need to prepare you to recognize those things that trigger you to relapse."

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? ID: 0215 | 22.xml #215

"We want to attend a support group."

A client scheduled to take a subcutaneous anticoagulant at home says to the nurse, "I'm not sure I will be able to take this medication at home." Which statement by the nurse is appropriate?

"What are your concerns about taking this medication at home?"

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns?

"What aspects of this situation are the most difficult for you?"

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? ID: 0206 | 22.xml #206

"What can I do for you?"

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?

"What do you find difficult about this situation?"

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? ID: 0825 | 66.xml #825

"What do you find difficult about this situation?"

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?

"What leads you to seek help now?"

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? ID: 0829 | 67.xml #829

"What leads you to seek help now?"

The nurse is preparing a client with schizophrenia with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? ID: 4422 | Mental Health Questions_final.htm #879

"When I have command hallucinations, I'll call a friend and ask him what I should do."

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? ID: 0813 | 65.xml #813

"When I have command hallucinations, I'll call a friend for help."

The nurse is providing dietary instructions to the client with anemia. The client tells the nurse that the iron pills are very expensive, and it will be difficult to pay for the pills and buy the proper food. What is the most appropriate nursing response?

"Would you like for me to check into some other options for you?"

A client is experiencing impotence after taking guanfacine. The client states, "I would sooner have a stroke than keep living with the effects of this medication." What is the most appropriate response by the nurse?

"You are concerned about the effects of your medication."

A client with nausea and bradycardia is admitted to a medical unit. The family hands the nurse a small white envelope labeled "heart pill." The envelope is sent to the pharmacy and it is found to be digoxin. A family member states, "That primary health care provider doesn't know how to take care of my family." Which statement would convey a therapeutic response by the nurse?

"You are concerned your loved one receives the best care."

A client is admitted to the hospital emergency department with an acute anterior wall myocardial infarction. The nurse discusses thrombolytic therapy with the client and spouse. The spouse is concerned about the dangers of this treatment. Which statement by the nurse is appropriate?

"You have concerns about whether this treatment is the best option."

The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue?

"You haven't had an appetite at all?"

A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved are dead." Which response demonstrates an understanding of therapeutic communication when dealing with a grieving client?

"You must be feeling all alone at this point."

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic?

"You need to grieve, and expressing anger can be part of grieving."

The nurse is instructing the caregiver of a child about reprimanding the child. The nurse recognizes that additional teaching is needed if the caregiver makes which statement to the child? ID: 2999 | Developmental Stages_Infancy to Adolescence_final.htm #3332

"You need to stop hitting your sister."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?

"You sound very upset. Are you thinking of hurting yourself?"

A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse?

"You will be safe here. Your thinking will be clearer after your medication starts to work."

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? ID: 0788 | 64.xml #788

"You're having difficulty sleeping?"

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? ID: 4400 | Mental Health Questions_final.htm #853

"You're having difficulty sleeping?"

The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client?

"You're wearing a new blouse."

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? ID: 4399 | Mental Health Questions_final.htm #852

"You've been feeling like a failure for a while?"

A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame?

1 week after the 3rd treatment session

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. ID: 2833 | Developmental Stages_End of Life Care_final.htm #934

1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply.

1."This document is a separate document from my final will." 4."This document describes the kind of treatment I want depending on how sick I am."

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply.

1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 6.Magnetic resonance imaging shows temporal lobe atrophy

Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.

1.Male gender 3.Abuses drugs as well as alcohol 5.History of at least 1 suicide attempt

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. ID: 2011 | Adult Health_Neuro Questions_final.htm #2424

1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 4.Looking directly at the client during attempts at speech

Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply.

1.The average series involves 8 to 12 treatments. 2.Some confusion may be noted after the procedure. 3.Memory loss may occur but will resolve with time.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. ID: 4398 | Mental Health Questions_final.htm #226

2. Looking at old photographs of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. ID: 0833 | 67.xml #833

2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply.

2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. ID: 2010 | Adult Health_Neuro Questions_final.htm #2423

2.Hyperoxygenating before suctioning 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply.

2.Is related to abnormal melatonin metabolism 4.Improves during the spring and summer months 5.Is a result of alterations in the available amounts of sunlight 6.A craving for carbohydrates lessens during sunnier and spring months

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. ID: 2849 | Developmental Stages_End of Life Care_final.htm #3217

2.Loss of consciousness 3.Loss of bowel control 4.Loss of bladder control 5.Decreased blood pressure 6.Decreased tactile sensation

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.

2.Panic disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. ID: 2832 | Developmental Stages_End of Life Care_final.htm #223

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse.

3.Encourage expression of feelings, concerns, and fears. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know they will not be abandoned by the nurse.

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply. ID: 4383 | Maternity_Postpartum_final.htm #4488

4."The client may complain of lack of sleep and fatigue." 5."The client is self-focused and talks to others about labor."

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? ID: 1297 | Adult Health_Eye Questions_final.htm #1464

A client who became deaf before learning to speak

The nurse is working at a Veterans Affairs clinic that provides services for homeless veterans. Which client should the nurse attend to first?

A client with a plan to harm himself

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?

A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? ID: 1968 | Adult Health_Neuro Questions_final.htm #2381

A long-term sequela of the injury

As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior?

A normal behavior that can occur during the termination period

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? ID: 4414 | Mental Health Questions_final.htm #871

A structured program of activities in which the client can participate

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? ID: 0792 | 64.xml #792

A willingness to participate in the planning of the care and treatment plan

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? ID: 1885 | Adult Health_Neuro Questions_final.htm #2298

Acknowledge the client's anger and continue to encourage participation in care.

The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect?

Acute confusion as a result of hospital-induced psychosis

Which most essential element should the nurse consider to promote client adherence to care recommendations?

Adhering to the client's cultural preferences

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? ID: 0796 | 64.xml #796

Admitting to having a problem

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? ID: 4407 | Mental Health Questions_final.htm #861

Admitting to having a problem

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? ID: 1865 | Adult Health_Neuro Questions_final.htm #784

Affect is flat, with periods of emotional lability

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? ID: 0719 | 58.xml #719

Affect is flat, with periods of emotional lability.

The nurse is preparing to teach ostomy care to a client who has just had a urinary diversion; the client expresses concern about body appearance. Which client action indicates that the best initial positive adaptation is being made? ID: 2202 | Adult Health_Renal Questions_final.htm #2695

Agrees to look at the ostomy

A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? ID: 2205 | Adult Health_Renal Questions_final.htm #2698

Altered body appearance related to change in the appearance of the scrotum

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? ID: 1741 | Adult Health_Musculoskeletal Questions_final.htm #2122

Altered body image

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate?

Always turns on the overhead light before entering a darkened room

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? ID: 1979 | Adult Health_Neuro Questions_final.htm #2392

Alzheimer's disease

The nurse determines that which client is at highest risk for suicide?

An 18-year-old who abuses both alcohol and drugs and who will not meet the requirements for graduation

\The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? ID: 0965 | Adult Health_Cardio Questions_final.htm #1006

An attempt to ignore or deny the need to make lifestyle changes

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

An expected coping mechanism

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? ID: 0893 | 70.xml #893

An expected coping mechanism

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all of the doctor's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement?

An expected coping mechanism

The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem? ID: 2163 | Adult Health_Renal Questions_final.htm #2656

Anger

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? ID: 2851 | Developmental Stages_End of Life Care_final.htm #3219

Anxiety

When communicating with a client who speaks a different language, which best practice should the nurse implement? ID: 2762 | Culture-Spirituality Questions_final.htm #2

Arrange for an interpreter to translate.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? ID: 0817 | 66.xml #817

Ask the client about the amount of drug use and its effect.

A client who has shared with the group at a previous session now suddenly gets up and announces, "I'm leaving." How can the nurse initially meet the needs of both the client and the group?

Ask the client to stay and share what he is feeling.

When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention?

Asking the client if she or he is dealing with some new stressor

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? ID: 2842 | Developmental Stages_End of Life Care_final.htm #3210

Assess the client's and the spouse's perception of the event.

A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? ID: 2659 | Complex Care_Emergency Situations_final.htm #3145

Assess the client's respiratory status and for the presence of neck injuries.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? ID: 1365 | Adult Health_GI Questions_final.htm #1522

Assist the client in expressing feelings.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? ID: 1932 | Adult Health_Neuro Questions_final.htm #2345

Associated with poor comprehension

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? ID: 0815 | 65.xml #815

Avoid using a whisper voice in front of the client.

Avoid using a whisper voice in front of the client. Disturbed thought processes related to paranoid personality disorder are the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder. Test-Taking Strategy(ies):Focus on the subject, interventions for paranoid personality disorder, and note the strategic word, best. Note that the client has paranoia; thinking about its definition will direct you to the correct option.Color Key:Cyan = Strategy

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?

Avoidant

The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers?

Barbiturate abuse is the cause of many drug overdose deaths.

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's sweet-16 birthday party, I'll be ready to die." The nurse notes that the client is experiencing which phase of coping? ID: 2845 | Developmental Stages_End of Life Care_final.htm #3213

Bargaining

A home care nurse is making home visits to an older client with urinary incontinence who is very concerned about the incontinent episodes. Which finding by the nurse indicates that the client has an environmental barrier to normal voiding? ID: 2191 | Adult Health_Renal Questions_final.htm #2684

Bathroom located on the second floor, bedroom on the first floor

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? ID: 1138 | Adult Health_Endocrine Questions_final.htm #1248

Body image changes

The parents of a newborn with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?

Cleft-lip repair is usually performed during the first months of life.

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia?

Coffee, tea, and soda consumption should be limited.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. ID: 0811 | 65.xml #811

Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? Concern about the loss of the baby and personal health

Concern about the loss of the baby and personal health

A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period? ID: 2065 | Adult Health_Oncology Questions_final.htm #2545

Concern about the outcome of surgery

Which assessment finding would be a manifestation associated with dementia?

Confabulation

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? ID: 0713 | 58.xml #713

Consistently uses adaptive equipment in dressing self

Conversion disorder

Convey empathy, trust, and respect toward the client.

The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called? ID: 2807 | Culture-Spirituality Questions_final.htm #3564

Cultural imposition

The nursing care plan indicates a problem of self-directed violence and the risk for suicide related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome?

Denies presence of suicidal ideations

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.

Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances

What is the most serious risk associated with the use of benzodiazepine?

Dependence

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? ID: 2886 | Developmental Stages_Health Assessment-Physical Exam_final.htm #3240

Difficulty walking

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury?

Diminishing the effectiveness of psychotropic medication

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse interprets that the client is using which coping mechanism? ID: 1445 | Adult Health_GI Questions_final.htm #1604

Distancing

The nurse is caring for a client postoperatively after creation of a colostomy. What is an appropriate potential client problem? ID: 1452 | Adult Health_GI Questions_final.htm #1611

Disturbed body image

The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?

Disulfiram

The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client?

Drawing

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation?

During the entire family visit, the client presented with an expressionless, blank look.

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? ID: 4287 | Maternity_Newborn_final.htm #4419

Encourage the parents to touch their newborn.

The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include?

Establish a therapeutic relationship.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? ID: 1877 | Adult Health_Neuro Questions_final.htm #2290

Explaining equipment and procedures on an ongoing basis

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? ID: 2341 | Adult Health_Respiratory Questions_final.htm #2838

Exposure to tuberculosis

The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs?

Flashbacks

A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy?

Fosters positive behavioral change

A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? ID: 1361 | Adult Health_GI Questions_final.htm #1518

Frequent need to work overtime on short notice

The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?

Guilt that they did not seek treatment more quickly

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? ID: 0795 | 64.xml #795

Helping the client to examine dysfunctional thoughts and beliefs

A client with depression verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response?

Identify recent behaviors or accomplishments that demonstrate the client's skills.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement?

Identify recent behaviors or accomplishments that demonstrate the client's skills.

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?

Impaired pain perception

A client has been prescribed pindolol for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance?

Impotence

The nurse notes that a client attending a group therapy session is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior?

Improvement

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? ID: 1743 | Adult Health_Musculoskeletal Questions_final.htm #2124

Inability to entertain self

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention?

Including the client's support system in the teaching

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving?

Increased number of hours slept at 1 time and is increasingly alert

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? ID: 1883 | Adult Health_Neuro Questions_final.htm #2296

Indicates that facial puffiness will be a permanent problem

The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care?

Individualized goals and objectives

The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? ID: 0802 | 64.xml #802

Inquiring about and examining the client's feelings for any that may block adaptive coping

The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate?

Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor

The nurse orienting a new client to a residential treatment center prepares to explain to the client that the emphasis of the center involves milieu therapy. Which is the focus of this type of therapy?

Involves group and social interaction with rules and expectations mediated by peer pressure

The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information? ID: 1158 | Adult Health_Endocrine Questions_final.htm #1268

It is normal during this time and will subside.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? ID: 2361 | Adult Health_Respiratory Questions_final.htm #2858

It is painless and safe.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? ID: 1878 | Adult Health_Neuro Questions_final.htm #2291

It is possible the client can hear the family.

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

Lack of ability to cope effectively

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?

Lack of naturally occurring endorphins

The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? ID: 2854 | Developmental Stages_End of Life Care_final.htm #3222

Lateral

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should incorporate which nursing action when working with this client? ID: 1620 | Adult Health_Integumentary Questions_final.htm #1975

Listening attentively

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. ID: 0176 | 19.xml #176

Looking at old snapshots of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received

The nurse is caring for a client with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority? ID: 2836 | Developmental Stages_End of Life Care_final.htm #3204

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation?

Making decisions about living arrangements after discharge

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? ID: 0801 | 64.xml #801

Milieu therapy

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? ID: 0794 | 64.xml #794

Monitor closely for harm to self or others.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. ID: 0818 | 66.xml #818

Monitor vital signs 2.Provide a safe environment. 3.Address hallucinations therapeutically. 5.Provide reality orientation as appropriate.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? ID: 0878 | 70.xml #878

Observing rigid rules and regulations

Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses' station. The client becomes very loud and offensive, and demands to be seen by the psychiatrist immediately. Which intervention will address the needs of both the client and the milieu?

Offer to assist the client to an examination room until the psychiatrist is notified.

A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety? ID: 2195 | Adult Health_Renal Questions_final.htm #2688

One kidney is adequate to meet the needs of the body as long as it has normal function.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? ID: 0090 | 12.xml #90

Page an interpreter from the hospital's interpreter services.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? ID: 2869 | Developmental Stages_Health Assessment-Physical Exam_final.htm #132

Page an interpreter from the hospital's interpreter services.

The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? ID: 2081 | Adult Health_Oncology Questions_final.htm #2561

Participating in the care of the surgical drain

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? ID: 0906 | 70.xml #906

Place a clock and calendar in the client's room.

A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board

The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?

Possible sexual abuse

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar?

Progressive muscle relaxation techniques are useful for easing tension from many causes.

The primary health care provider (PHCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the PHCP's prescription and address the needs of the client? ID: 3759 | Fundamentals of Care_Safety_final.htm #4013

Progressively ambulate the client in the hall 3 times daily.

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client?

Provide a structured daily program of activities, and encourage the client to participate.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

Provide authority, action, and participation.

A client diagnosed with depression is not eating adequately and at times even refuses to eat at all. What should the nurse plan to do to meet the client's nutritional needs?

Provide small, frequent meals that include the client's food preferences.

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? ID: 3853 | Leadership-Management_Delegating_final.htm #4091

Providing distraction for the client by engaging the client in a board game

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? ID: 0718 | 58.xml #718

Providing information, giving positive feedback, and encouraging relaxation

The nurse is caring for a client who has been taking hydrocodone for the last 3 months. For which side and adverse effects of this medication should the nurse assess the client?

Psychological and physical dependence

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?

Reactions to a devastating event

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? ID: 0831 | 67.xml #831

Reactions to a devastating event

A client who has a history of being sexually assaulted is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism?

Regression

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action?

Remain with the client until the anxiety decreases.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time?

Remain with the client.

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time?

Remaining with the client

During morning rounds the nurse comes into the room of a client who is unresponsive and near death. Two assistive personnel (APs) are bathing the client, and their conversation centers on their plans for a weekend party. How should the nurse best intervene? ID: 2863 | Developmental Stages_End of Life Care_final.htm #3231

Remind the APs, "Remember that Mr. Smith can hear everything you are saying!"

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. ID: 0799 | 64.xml #799

Restating Active listening Maintaining neutral responses Providing acknowledgment and feedback

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client?

Rigidness in thought and inflexibility

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? ID: 4417 | Mental Health Questions_final.htm #874

Setting limits on the client's behavior

The nurse is monitoring a stress management therapy group that is in the forming stage. Which activity is characteristic of this stage of group development?

Setting the rules of conduct for members of the stress management group

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget?

Share the observation with the client so the behavior can be recognized.

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy?

Short exposure to the phobic object

The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms?

Signs may appear at any time.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action?

Sit and talk with the client about the feelings.

The nurse is caring for a client just admitted to the mental health unit and is displaying immobile and mute behaviors and is withdrawn. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? ID: 4423 | Mental Health Questions_final.htm #880

Sit beside the client in silence with occasional open-ended questions.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? ID: 0814 | 65.xml #814

Sit beside the client in silence with simple open-ended questions.

Which client behavior demonstrates denial of a sexual abuse event?

Sitting quietly and calmly reading a magazine

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?

Somatization disorder

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? ID: 1097 | Adult Health_Ear Questions_final.htm #759

Speak at a normal volume.

During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech?

Speech is illogical and loosely associated.

Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action?

Station mental health professionals at established assistance centers.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? ID: 0257 | 25.xml #257

Support the mother in her reaction to the newborn infant.

The nurse is preparing to perform a pediatric physical examination. The child refuses to sit on the examining table, screams when the nurse attempts to perform the assessment, and does not make eye contact. What is the most appropriate initial nursing action?

Talk to the parent while ignoring the child.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? ID: 0800 | 64.xml #800

Thank the client for the input, but inform the client that others now need a chance to contribute.

A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement?

The charge nurse blames staff for wasting supplies.

The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. Which is the correct interpretation of the behavior? ID: 2979 | Developmental Stages_Infancy to Adolescence_final.htm #3312

The child exhibits detachment.

The nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which behavior indicates to the nurse that the client is not ready to learn? ID: 1224 | Adult Health_Endocrine Questions_final.htm #1334

The client complains of fatigue whenever the nurse plans a teaching session.

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression?

The client constantly complains of tiredness and fatigue.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect?

The client giggled while describing being physically abused as a child.

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli?

The client is convinced that the curtains are actually ghosts.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior?

The client is displaying typical behaviors.

The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? ID: 2061 | Adult Health_Oncology Questions_final.htm #2541

The client looks at the surgical site.

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact?

The client regularly reexperiences the events associated with the assault.

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse?

The client verbalizes stages of grief and plans to attend a community grief group.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior?

The client will employ new coping methods that will resolve the problem.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia?

The client's noncompliance with medication therapy

The nurse should plan which goals of the termination stage of group development? Select all that apply.

The group evaluates the experience. The group explores members' feelings about the group and the impending separation.

The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle?

The group should be limited to no more than 10 members.

The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? ID: 0009 | 5.xml #9

The history

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression?

The mother constantly complains of tiredness and fatigue.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? ID: 4345 | Maternity_Postpartum_final.htm #4450

The mother requests that the nurse feed the newborn because she is feeling fatigued.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? ID: 0908 | 70.xml #908

The need for sensory stimulation

The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client? ID: 2799 | Culture-Spirituality Questions_final.htm #3556

The nurse secures the assistance of a professional interpreter to communicate with the client.

A client with suspected opioid overdose has received a dose of naloxone hydrochloride. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information?

These are signs of opioid withdrawal.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? ID: 2343 | Adult Health_Respiratory Questions_final.htm #2840

This is expected, and the client should gradually increase activity as tolerated.

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention?

Turn off the television.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? ID: 4413 | Mental Health Questions_final.htm #870

Use an indirect light source and turn off the television.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

Use of confabulation

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? ID: 4401 | Mental Health Questions_final.htm #854

Using open-ended questions and silence

The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency?

When asked to pick up the cup, the client consistently fails to identify the cup.

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? ID: 1978 | Adult Health_Neuro Questions_final.htm #2391

Whether this is a change in usual level of orientation

Which is a primary behavior of a client diagnosed with antisocial personality disorder?

Will take personal items from other clients' rooms

The nurse in the primary health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? ID: 2124 | Adult Health_Oncology Questions_final.htm #2604

These sensations dissipate over several months and usually resolve after 1 year.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? ID: 0877 | 70.xml #877

Use of confabulation

"Can you share with me what you've been told about your surgery?"

Which statement should the nurse initially make to a client who is anxious about having a magnetic resonance imaging test? ID: 3168 | Fundamentals of Care_Diagnostic Tests_final.htm #3933

"Can you tell me what you know about this test?"

A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First, my brother dies of cancer; then my husband leaves me for a 20-year-old. I wish I had 1 of those pills right now." Which statement by the nurse would be therapeutic?

"Can you tell me what you think the pills can do for you?"

Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide?

"Discussing suicide with a client is not harmful."

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? ID: 4412 | Mental Health Questions_final.htm #869

"Do you feel afraid that people are trying to hurt you?"

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client?

"Do you feel afraid that people are trying to hurt you?"

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? ID: 0819 | 66.xml #819

"I no longer feel that I deserve the beatings my husband inflicts on me."

The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment?

"I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the primary health care provider (PHCP) that the client had terminal cancer. The PHCP examines the client and asks the nurse to contact the medical examiner regarding an autopsy. Family members of the client tell the nurse that they do not want an autopsy performed. Which response to the family is appropriate? ID: 2837 | Developmental Stages_End of Life Care_final.htm #3205

"I will contact the medical examiner regarding your request."

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? ID: 0894 | 70.xml #894

"I will contact the medical examiner regarding your request."

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement? ID: 1306 | Adult Health_Eye Questions_final.htm #1473

"I will raise the volume of my hearing aid."

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis?

"I'd be sure to have a panic attack if I left my house."

A client with cancer is placed on permanent total parenteral nutrition (TPN). The nurse considers psychosocial support when planning care for this client when the client makes which correct statement? ID: 2751 | Complex Care_Parenteral Nutrition_final.htm #3195

"I'll need to adjust to the idea of living without eating by the usual route."

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? ID: 1363 | Adult Health_GI Questions_final.htm #1520

"I'm not sure that I understand. Would you please explain?"

A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response?

"It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? ID: 1373 | Adult Health_GI Questions_final.htm #1530

"Tell me more about your concerns with your diet after going home."

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? ID: 1778 | Adult Health_Musculoskeletal Questions_final.htm #2159

"The cane has a flared tip with concentric rings to give stability."

A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? ID: 4003 | Maternity_Antepartum_final.htm #4184

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? ID: 1668 | Adult Health_Integumentary Questions_final.htm #2023

"The local anesthetic may cause a burning or stinging sensation."

The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? ID: 1607 | Adult Health_Integumentary Questions_final.htm #1962

"The local anesthetic may cause a stinging sensation."

The nurse should interpret which comment by a client diagnosed with battered wife syndrome as being consistent with the presence of low self-esteem?

"Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it was decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear?

"This aching and cramping is normal and temporary and will subside."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"This form of therapy provides a negative reinforcement when the stimulus is produced."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? ID: 0927 | 70.xml #927

"This form of therapy provides a negative reinforcement when the stimulus is produced."

The mother of a 5-year-old child tells the nurse that the child scolds the floor or a table if she hurts herself on the object. The nurse educates the mother according to Piaget's theory of cognitive development and its terminology and definitions. Which statement by the mother indicates that the teaching has been effective? ID: 2997 | Developmental Stages_Infancy to Adolescence_final.htm #3330

"This is an example of animism."

The mother arrives at a well-baby clinic with her 1-month-old infant. She expresses concern because one of the infant's eyes appears to be crossed. What is the nurse's best response?

"This is normal in the young infant but should not be present after the age of about 4 months."

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? ID: 1125 | Adult Health_Endocrine Questions_final.htm #1235

"Usually these physical changes slowly improve following treatment."

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

"What is causing you to behave so agitated?"

The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning?

"When your psychiatrist arrives on the unit, I will let them know that you have a question."

A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern?

"Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs?

"You don't have to sing. Just listen and enjoy the music."

The client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which statement is the appropriate response by the nurse? ID: 1227 | Adult Health_Endocrine Questions_final.htm #1337

"You have concerns about the surgical treatment for your condition?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?

"You seem restless; tell me what is happening."

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? ID: 0827 | 67.xml #827

"You seem restless; tell me what is happening."

A client states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which response by the nurse will best address the client's low sense of self-esteem?

"You seem very discouraged. Let's identify something that you are proud of doing."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

A client diagnosed with depression says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response should the nurse make at this time to assess the client's state of mind?

"You sound very unhappy. Are you thinking of harming yourself?"

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? ID: 0832 | 67.xml #832

"You sound very upset. Are you thinking of hurting yourself?"

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman? ID: 4062 | Maternity_Antepartum_final.htm #4243

"You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed."

"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart below.History and PhysicalLaboratory and Diagnostic ResultsMedicationsGravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0Venereal Disease Research Laboratory (VDRL) nonreactivePrenatal vitaminsWeight 135 lb (61 kg)Rubella immune Positive Goodell and ChadwickRh positive, Type O

"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. ID: 2161 | Adult Health_Renal Questions_final.htm #2654

1.Agitation 3.Depression 4.Withdrawal 5.Labile emotions

The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply.

1.Ask permission before touching the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply.

1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 4.Offer small high-calorie, high-protein snacks during the day and evening.

Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply.

1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3..Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. ID: 4420 | Mental Health Questions_final.htm #877

1.Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. ID: 4430 | Mental Health Questions_final.htm #887

1.Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances

The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply. ID: 2791 | Culture-Spirituality Questions_final.htm #3548

1.Increasing client safety 2.Using spiritual practices 3.Reducing health disparities 4.Increasing client satisfaction 6.Preventing misunderstandings between the nurse and the client

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. ID: 4427 | Mental Health Questions_final.htm #884

1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 5.Provide reality orientation as appropriate. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Thinking about the needs of the client in alcohol withdrawal and recalling the characteristics associated with alcohol withdrawal will assist in answering correctly. Also, use therapeutic communication techniques to assist in selecting the correct interventions.Color Key:Cyan = Strategy When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. ID: 4408 | Mental Health Questions_final.htm #864

1.Restating 2.Listening 4.Maintaining neutral responses 5.Providing acknowledgment and feedback

The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. ID: 2848 | Developmental Stages_End of Life Care_final.htm #3216

1.Retain ritualism. 2.Avoid significant changes in lifestyle. 3.Maintain sensitivity toward the parents. 4.Encourage the parents to be near the child. 5.Encourage as normal an environment as possible.

A client with a medical diagnosis of breast cancer is undergoing chemotherapy. The client complains to the nurse about losing her hair and severe fatigue from the treatment. Which interventions should the nurse implement for this client? Select all that apply. ID: 2118 | Adult Health_Oncology Questions_final.htm #2598

1.Review side effects of chemotherapy and treatment with the client. 3.Teach the client to pace activities with rest so as to maintain strength. 4.Offer information on available counseling services and support groups. 6.Inquire how the cancer diagnosis and treatment affect the client's normal routine.

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply.

1.The client will keep scheduled appointments. 2.The client's physical wounds will begin to heal properly. 3.The client will verbalize feelings about the abusive event. 5.The client will participate in the various aspects of the treatment plan.

A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? ID: 1750 | Adult Health_Musculoskeletal Questions_final.htm #2131

Body image alteration

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? ID: 0793 | 64.xml #793

Contact the client's primary health care provider (PHCP).

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? ID: 1938 | Adult Health_Neuro Questions_final.htm #2351

Emphasize progress in a realistic manner.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know they will not be abandoned by the nurse.

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention? ID: 2847 | Developmental Stages_End of Life Care_final.htm #3215

Encourage the client to maintain maximum self-control.

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections? ID: 4072 | Maternity_Antepartum_final.htm #4253

Establish a therapeutic relationship.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care?

Establish a trusting nurse-client relationship.

Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship?

Establishing the parameters of the relationship

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?

Evidence of the client's disturbed body image

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? ID: 4411 | Mental Health Questions_final.htm #867

Inquiring about and examining the client's feelings for any that may block adaptive coping

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? ID: 0942 | 70.xml #942

Lack of ability to cope effectively

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the child's face.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action? ID: 0357 | 35.xml #357

Let the mother hold the child and direct the cool mist over the child's face.

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach? ID: 4410 | Mental Health Questions_final.htm #866

Milieu therapy

Monitor closely for harm to self or others.

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support?

Post-traumatic stress disorder

A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? ID: 1791 | Adult Health_Musculoskeletal Questions_final.htm #2172

Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection

A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals? ID: 1456 | Adult Health_GI Questions_final.htm #1616

Practicing proper cutting of the ostomy appliance

The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? ID: 2159 | Adult Health_Renal Questions_final.htm #2652

Presence of family

The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking?

Present verbal instructions regarding expectations in single, simple commands.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? ID: 0938 | 70.xml #938

Provide authority, action, and participation.

What is the appropriate nursing intervention in dealing with a suicidal client?

Provide authority, action, and participation.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? ID: 2342 | Adult Health_Respiratory Questions_final.htm #2839

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior?

Repetitive actions to manage anxiety

The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action? ID: 2804 | Culture-Spirituality Questions_final.htm #3561

Request permission to move the client to a private room and allow the family members to visit.

Which client's death was achieved by what is considered a soft suicide method?

Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? ID: 4409 | Mental Health Questions_final.htm #865

Thank the client for the input, but inform the client that others now need a chance to contribute.

When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor?

The client has 2 family members who have abused.

The need for sensory stimulation

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. ID: 0883 | 70.xml #883

The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

A client who was started on clonazepam tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse's response is based on which understanding?

These symptoms are most severe during initial therapy and decrease or disappear with long-term use.

The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings?

Use open-ended questions and silence.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? ID: 0789 | 64.xml #789

Using open-ended questions and silence

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