NURS128 LESSON 2 QUESTIONS

A nurse is discussing the possible existence of abuse related to a 4 year old currently being treated in the emergency department. Which statement by the nurse requires immediate intervention? "We don't need physical proof of injury to report this situation." "A 4 year old can be an unreliable source since they have such wonderful imaginations." "It's up to the state's child protection agency to determine if our fears are valid." "I'm absolutely sure every state requires that we report our concerns."

"A 4 year old can be an unreliable source since they have such wonderful imaginations."

Which nursing assessment question is focused on evaluating for the most prevalent comorbid mental ill issue among the clients diagnosed with anxiety disorder?" "Do you ever engage in binge eating?" "Are you hearing voices that no one else can hear?" "Can you tell me the names and ages of your grandchildren?" "Are you currently experiencing any suicidal ideations?"

"Are you currently experiencing any suicidal ideations?"

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager? "On a regular basis, do you get enough restful sleep?" "Am I correct to say that you try to avoid certain family members?" "Are you experiencing a flashback of the rape right now?" "Can we discuss what triggered your angry outburst a few minutes ago?"

"Are you experiencing a flashback of the rape right now?"

Which question demonstrates the nurse's understanding of the need to assess a client who has been physically abused for additional forms of trauma? "What types of injuries have you received as a result of the physical abuse?" "Do you know what triggers the physical abuse?" "Did your abuser ever intimidate or threaten you with physical harm?" "Can you tell me when the physical abuse began?"

"Can you tell me when the physical abuse began?"

A client, being cared for in the emergency department (ED) after a sexual assault, asks that a friend be allowed to stay in the examination room while waiting for the SANE nurse to arrive. The client is observably anxious and states, "I don't want to be alone." What response will the ED nurse make in order to best assure the client's safety and emotional health? "I understand. I'll stay with you." "Are you thinking about hurting yourself?" "Certainly; whatever makes you feel safe." "Do you want to talk to a psychiatrist?"

"Certainly; whatever makes you feel safe."

Which statement demonstrates a characteristic of depression-associated behaviors that is especially associated with children and adolescents? "I can't go on being so depressed." "Life is no fun since I lost my sister." "I don't care that friends say I'm grumpy." "I'm so very sad since my sister died."

"I don't care that friends say I'm grumpy."

A client is currently expressing suicidal ideations. Which statement made by the client demonstrates knowledge of appropriate crisis management techniques that are focused on safety? "I know the thoughts will likely go away." "I need you to stay with me." "I have survived the urge to kill myself before." "I trust the staff here to help."

"I need you to stay with me."

Which response is characteristic of the implementation of an immature defense mechanism? Giving an expense gift to someone who you took advantage of. Drinking alcohol to get the courage to ask for a salary increase. "I'm not a bully; it's just that people are envious of how rich I am." "I only steal from stores that overcharge for the products in the first place."

"I only steal from stores that overcharge for the products in the first place."

A client has been receiving treatment for posttraumatic stress disorder (PTSD) after experiencing a sexual assault. Which statement supports that the client is able to resume pre-trauma function? "I really like my therapist." "I'm hopeful that life will get back to normal." "I'm being considered for a promotion at work." "I'm feeling less anxious among strangers."

"I'm being considered for a promotion at work."

Which statement, by a client diagnosed with poor impulse control, indicates an improved prognosis? "My children will stop loving me if I continue to act this way." "I feel so badly when I act on my anger." "I've learned to walk away when I start feeling angry." "Being angry is ruining my life."

"I've learned to walk away when I start feeling angry."

Which statement by a client scheduled for a series of electroconvulsive therapy (ECT) treatments indicates to the nurse that the client has an understanding of the goals of this treatment? "My prognosis is so much better since I didn't have any delusional symptoms." "If this works, I will likely be able to stop taking lithium." "I'm prepared to deal with the certain loss of my short-term memory." "It is expected that my chance for remission is very good."

"It is expected that my chance for remission is very good."

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? "Your life is much better now. You will feel better soon." "Don't worry. We can try taking it at a different time of day to help it work better." "I will call your care provider. Perhaps you need a different medication." "It usually takes a few weeks for you to notice improvement from this medication."

"It usually takes a few weeks for you to notice improvement from this medication."

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? "The person may experience decreased energy and interest in activities beginning in the winter months." "The person may have excess energy, talk a lot, feel restless, and spend too much money." "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite."

"The person may have excess energy, talk a lot, feel restless, and spend too much money."

A nurse has worked on a mental health unit for an extended period of time. Which statement is best associated with behaviors demonstrated as a result of compassion fatique? "I'm really looking forward to the day I can retire and travel." "The clients often behave in a manner that makes them unlikable." "These clients are like living with my mother and aunt." "I'm so tired; having a 4-day stretch off will be so wonderful."

"These clients are like living with my mother and aunt."

A client became angry with a staff member and began throwing objects at others in the unit. Which question will the nurse manager ask the staff in order to address the goals of the debriefing of the incident that focuses on client care? "What injuries resulted from the violence?" "Were the unit's policies on managing violence followed?" "What was the client's reasoning for the violent behaviors?" "When did the violence begin?"

"Were the unit's policies on managing violence followed?"

A client has expressed great concern over "feeling like I'm going crazy" since experiencing anxiety, depression, and nightmares after being sexually assaulted. What response will the nurse make initially to address the client's concerns? "What you are experiencing is common among assault victims. It's not a result of going crazy." "Let's talk about how these symptoms are making you feel and especially how they are making you feel crazy." "These are common feelings after being assaulted. Fortunately you are not going crazy so try not to worry." "What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted."

"What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted."

Which nursing assessment question is focused on determining the client's motivation for binge eating? "Does binging help you get the attention you need?" "Would you say that you are less depressed after binging?" "Are you less likely to hear voices while you are binging?" "Do you sleep better at least temporarily after binging?"

"Would you say that you are less depressed after binging?"

Which client-focused change will the nurse identify as a sign of possible escalation of anger? An impulsive client demonstrates introspection. A depressed client begins to cry. A quiet client becomes talkative and loud. A manic client becomes withdrawn.

A quiet client becomes talkative and loud.

A nurse managing the care of a client diagnosed with an eating disorder has begun to experience frustration when the client consistently pushes back against the planned interventions. What action on the part of the nurse is indicated to help strengthen the nurse-client relationship? Regularly sharing with peers the feelings and asking for their suggestions on minimizing the frustration Demonstrating a very matter-of-fact attitude when addressing issues related to interventions Acknowledging to the client that working toward these treatment goals must be very frightening Asking that a more experienced nurse be allowed to act as monitor in order to identify any existing countertransference

Acknowledging to the client that working toward these treatment goals must be very frightening

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for interpersonal violence should be addressed in the workshop? Poor working conditions Hypertension medications Alcohol use Poor self-esteem

Alcohol use

The nurse will encourage the client to engage in regular involvement with which formalized groups as an intervention directed toward the treatment of a primary risk factor associated with depression? (Select all that apply.) Alcoholics Anonymous (AA) Senior citizens travel group Sexual assault survivors group New moms support group Church-associated men's group

Alcoholics Anonymous (AA) Sexual assault survivors group New moms support group

Lithium is prescribed for a client admitted with a diagnosis of bipolar disorder. Which other therapy is also initially prescribed to temporarily help manage the client's symptoms? Antipsychotic medication Antimanic medication Electroconvulsive therapy (ECT) Cognitive behavioral therapy (CBT)

Antipsychotic medication

Which statements are true regarding anxiety? (Select all that apply.) Anxiety is uncommon in women. Anxiety is a response to stress. Anxiety can cause elevations in blood pressure and heart rate. Children are at the highest risk for anxiety. Patients with anxiety respond well to relaxation techniques. Many conditions are exacerbated by stress and anxiety.

Anxiety is a response to stress. Anxiety can cause elevations in blood pressure and heart rate. Patients with anxiety respond well to relaxation techniques. Many conditions are exacerbated by stress and anxiety.

How will the nurse best assess a client for the current presence of suicidal ideations? Carefully observe the client's nonverbal behaviors. Determine whether the client has ever acknowledged suicidal ideations. Ask the client directly, "Are you thinking of killing yourself?" Place the client on one-on-one suicide observation.

Ask the client directly, "Are you thinking of killing yourself?"

Which nursing intervention will best address the intense need to control demonstrated by a client receiving treatment of bulimia nervosa? Monitoring the client for the presence of suicidal thoughts and behaviors Clearly stating expectations and admitting that they differ from those of the client Helping the client reframe irrational thinking that leads to dysfunctional eating Having the client keep a journal that identifies triggers that cause dysfunctional eating

Clearly stating expectations and admitting that they differ from those of the client

Which assessment data confirms that the client diagnosed with anorexia nervosa has achieved a fundamental treatment outcome? Acknowledges that symptoms of depression exist. Client has eaten 60% of three meals per day for 3 consecutive weeks. Demonstrates an understanding of what constitutes healthy eating habits. Client has maintained weight at 87% of ideal body weight for 2 months.

Client has maintained weight at 87% of ideal body weight for 2 months.

The nurse is assessing a patient's anxiety related to stress. Which changes reflect the short-term physiological response to stress? (Select all that apply.) Corticosteroid release increases stamina and impedes digestion. Immune system functioning decreases, and the risk of cancer increases. Risk of depression, autoimmune disorders, and heart disease increases. Epinephrine is released, increasing the heart and respiratory rates. Cortisol is released, increasing glycogenesis and reducing fluid loss. Muscular tension, blood pressure, and triglyceride levels increase.

Corticosteroid release increases stamina and impedes digestion. Epinephrine is released, increasing the heart and respiratory rates. Cortisol is released, increasing glycogenesis and reducing fluid loss. Muscular tension, blood pressure, and triglyceride levels increase.

The nurse is assessing a 4-year-old child in a health clinic. Which situation should cause the nurse to explore for possible abuse? The caregiver reporting angry outbursts from the child while they were in a store Being brought to the clinic from daycare Recent scrapes and bruises on both knees Different explanations of the injury from the child's parents

Different explanations of the injury from the child's parents

A client recently diagnosed as obese is experiencing stress related to the need to lose weight. How can the nurse best help the client focus on the eustress nature of this stressor? Encourage the client to discuss his or her feelings about being obese. Discuss weight loss strategies with the client. Re-enforce for the client that obesity is a health problem that is manageable. Provide the client with a list of realistic, time-focused weight loss goals.

Discuss weight loss strategies with the client.

Which intervention associated with bipolar disorder best minimizes the risk for the development of suicidal ideations? Stress identification Early diagnosis Medication therapy Family counseling

Early diagnosis

What is the foundational principle to consider when assessing clients from varying ethnic cultures for behaviors associated with anxiety disorders? There are basic anxiety-driven behaviors demonstrated by all cultures. Asian Americans are least reluctant to seek psychiatric help. Effective diagnosis of anxiety is dependent on an awareness of cultural norms. Anxiety triggers somatic symptoms more prevalently than cognitive ones.

Effective diagnosis of anxiety is dependent on an awareness of cultural norms.

When considering the lethality of a client's suicide plan, what is the basic principle the nurse will consider? If the action is reversible, the plan is less lethal. A gun can easily deliver a fatal wound. Ingesting pills is a slow method of self-harm. Any suicide plan has the potential to be lethal.

If the action is reversible, the plan is less lethal.

After the admission interview and assessment, the emergency department nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused? Insist that the child be further assessed without the parents being present. Delay the assessment until the appropriate child protection authorities are present. Allow the child to pick one parent to be present during the remaining examination. Provide the child with suggestions of other possible examples of abuse.

Insist that the child be further assessed without the parents being present.

The nurse is managing care for a client who is reporting increased stress related to a new work-related position. What intervention suggested by the nurse is associated with an increase of energy and fewer muscle aches? Adding Vitamin C to the daily diet Limiting or eliminating caffeine from diet Being screened for depression Monitoring heart and respiratory rates daily

Limiting or eliminating caffeine from diet

A client diagnosed with depression has been prescribed various first-line antidepressant agents but has demonstrated only minimal improvement. In preparation for the prescription of a second-line agent, the nurse will educate the client on which classification of antidepressant? Atypical Monoamine oxidase inhibitors Tricyclic Dual action

Monoamine oxidase inhibitors

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) Monitor for a decrease in respiratory rate. Observe for increased appetite. Assess for bradycardia. Ask about epigastric pain. Check for elevated blood glucose levels.

Observe for increased appetite. Ask about epigastric pain. Check for elevated blood glucose levels.

There is reason to believe that a client unknowingly ingested flunitrazepam prior to being sexually assaulted. Which intervention will the nurse implement in order to confirm this suspicion? Obtain a bedside electrocardiogram. Obtain a urine sample. Assess what the client drank before the assault. Assess the client's pupils.

Obtain a urine sample.

What classic characteristic is noted in clients diagnosed with bulimia nervosa? Involved in sports Obesity Male Onset in late adolescence

Onset in late adolescence

The nurse is implementing a nonpharmacological intervention for a patient with anxiety. Which intervention is most appropriate? Decreasing physical activity Performing abdominal breathing exercises Increasing caffeine intake Limiting noise or music in the room

Performing abdominal breathing exercises

A client is seeking treatment in the emergency department (ED) after a sexual assault. Which notation made by the ED nurse demonstrates appropriate nonjudgmental documentation? An alleged sexually assaulted inside a local parking garage was made by the client. Physical evidence supports that vaginal penetration occurred. Treatment for facial abrasions was refused. No acute emotional distress during assessment was noted.

Physical evidence supports that vaginal penetration occurred.

Which nursing intervention has priority during the acute phase of a client's manic episode? Monitoring the amount of sleep the client achieves Identifying triggers for exacerbation of manic behavior Providing fluids frequently to promote hydration Including family in regular counseling and therapy sessions

Providing fluids frequently to promote hydration

Which statement by a nursing student about the effects of the fight or flight response indicates a need for further education? Pupils constrict when a patient is anxious. Peristalsis slows as the patient decides whether to fight back. The patient may complain of dry mouth when anxious. The heart races when a patient experiences anxiety.

Pupils constrict when a patient is anxious.

Which life event related to a client demonstrating depressive symptoms supports a diagnosis of persistent depressive disorder (PDD)? Lost employment as a result of frequent absences Two unsuccessful suicide attempts over the last year Recognized symptoms of depression over 2 years ago Abruptly ended a long-term romantic relationship

Recognized symptoms of depression over 2 years ago

Which teaching-focused intervention will have the greatest impact on reducing the risk of relapsing for a client diagnosed with bipolar disorder? Role of family as support Stress management skills Available social resources Symptom recognition

Role of family as support

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? Antisocial personality Seasonal affective disorder Anxiety Medication side effects

Seasonal affective disorder

A patient who is at a health clinic reports a sore throat and is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? Primary prevention Tertiary prevention Secondary prevention Modified prevention

Secondary prevention

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder? Ensuring that the client's medication therapy is administered in a timely manner Instructing the client that intrusive behaviors are not appropriate Educating the client to the policies upon admission to the unit Setting and maintaining consistent unit policies that are enforced by all staff

Setting and maintaining consistent unit policies that are enforced by all staff

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. What factors should the case management nurse assess for at the facility? (Select all that apply.) Documentation of prescribed physical therapy sessions Skin breakdown in residents resulting from poor hygiene Altered cognitive function of residents Unexplained bruising of residents High ratio of overweight residents

Skin breakdown in residents resulting from poor hygiene Altered cognitive function of residents

Which action is an example of anger? Setting fire to the business that hires illegal immigrants Proposing radical changes to the way police manage public protesters at a town meeting Slapping a spouse in the face during an argument about the family budget Writing a scathing letter to the local newspaper regarding corrupt local politicians

Slapping a spouse in the face during an argument about the family budget

The nurse is caring for a patient newly diagnosed with major depressive disorder. What typical signs and symptoms would the nurse expect? (Select all that apply.) Increased fever Slowed speech Increased white blood cell count Appetite changes Poor eye contact

Slowed speech Appetite changes Poor eye contact

A client with a history of being bullied has been admitted to the hospital for treatment of anger issues. Which classic reaction will the nurse address in the client's plan of care? Suicidal ideations Hallucinations Somatic pain Paranoia

Suicidal ideations

Which intervention will the nurse include in the plan of care to address a common co-morbid condition demonstrated by many clients diagnosed with body dysmorphic disorder (BDD)? Set and enforce reasonable limits regarding boundaries Frequent re-orientation to time and place Suicide precautions Anger management group

Suicide precautions

A client has made a successful suicide attempt while hospitalized on a unit that specializes on the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement? All group therapy sessions will be held on the unit for at least a 72-hour period. Suicide precautions for a full 24 hours will be implemented for all clients. Every client will be questioned concerning the impact the suicide had on him or her personally. A client-focused psychological postmortem assessment will be conducted immediately.

Suicide precautions for a full 24 hours will be implemented for all clients.

A nurse is planning interventions for a veteran who has recently been discharged from the military and is reporting difficulty sleeping. When considering the client's past medical history, which data is most relevant to the development of posttraumatic stress disorder (PTSD)? Family history of depression Regularly smoked marijuana as a teenager Quit smoking tobacco 2 months ago Sustained a concussion a month before discharge

Sustained a concussion a month before discharge

An older adult has experienced both physical and emotional abuse while living with a family member. The family member has been adherent with required therapy and at the client's request the two will again be living together. Which intervention will best assure that both the client and the family member's needs are being met? The family member is informed that criminal charges will be filed if any abuse occurs. The client agrees to report any incidences of abuse by the family member immediately. Initially, 7 days a week, 24-hour home aides are provided. The home will have regular but unscheduled visits by adult protective services agents.

The home will have regular but unscheduled visits by adult protective services agents.

A nurse is conducting a family assessment to identify possible triggers for abusive behaviors. Which family characteristic will the nurse identify as such a trigger? The father is the "stay-at-home parent." The parents are of different ethnic and religious backgrounds. The parents were teenagers when the children were born. The family only socializes with other immigrant families.

The parents were teenagers when the children were born.

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? The patient may be having an acute psychotic episode related to her mental illness. The patient may be a very demanding and particular person. The patient may be abusing street drugs and needs a drug screening test. The patient may have been the victim of an acute assault.

The patient may have been the victim of an acute assault.

When considering an individual's risk for suicide, which client will the nurse consider the priority? The older transgender female who has been repeatedly assaulted The resent Middle Eastern immigrant from a war torn country The teenager recovering from a self-inflicted gunshot wound The gay male who has been diagnosed with HIV

The teenager recovering from a self-inflicted gunshot wound

Which patient behaviors noted by the nurse supports the diagnosis of severe level panic? Pacing nervously. Too preoccupied to respond when unit fire alarm is tested. Repeatedly demands that the staff, "make the voices stop saying those bad things." Reports being, "too nervous to eat."

Too preoccupied to respond when unit fire alarm is tested.