Psych - Test 3 - ATI & End of Chapter Questions

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

"Acquaintance rape often involves alcohol."

Statements that are examples of unacceptable behaviors under JCAHO standards for a culture of safety.

"Don't page me again, I'm very busy." "If you tell my supervisor, you'll never hear the end of it." "I haven't seen such stupid behavior since grade school."

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make?

"I am your nurse. Let's walk together to your room."

Which of the following is an example of assertive communication?

"I feel angry when you walk away when I'm talking."

Which of the following statements indicates the caregiver's accurate knowledge about the needs of a parent at the onset of the moderate stage of dementia?

"I need to spend time with my parent doing things we both enjoy."

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?

"I will administer prophylactic treatment for sexually transmitted infections, like chlamydia."

Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse?

"I will try to find new and different things to do every day."

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of a group indicates an understanding of teaching?

"Pregnancy increases the risk for violence toward the intimate partner."

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?

"Stop screaming, and walk with me outside."

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make?

"Tell me about how you are feeling right now."

The nurse has been teaching a caregiver about donepezil (Aricept). The nurse knows that teaching has been effective by which of the following statements?

"This medication will slow the progress of Alzheimer's disease temporarily."

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make?

"You believe this wouldn't have happened if you hadn't been out alone?"

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?

"You can expect the progression of cognitive decline to slow with donepezil."

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?

"You'd better listen to me."

A female client comes to an urgent care clinic and says, "I've just been raped." What should the nurse do? Allow the client to express whatever she wants. Ask the client if staff can call a friend or family member for her. Offer the client coffee, tea, or whatever she likes to drink. Get the examination completed quickly to decrease trauma to the client. Provide the client privacy—let her go to a room to make phone calls. Stay with the client until someone else arrives to be with her.

* Allow the client to express whatever she wants. * Ask the client if staff can call a friend or family member for her. * Stay with the client until someone else arrives to be with her.

Education for clients with PTSD should include which of the following?

* Avoid drinking alcohol. * Eat well-balanced, nutritious meals. * Find and join a support group in the community. * Get regular exercise, such as walking.

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.)

* Defensive responses to questions * Facial grimacing * Agitation

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.)

* Difficulty concentrating on tasks * Negative self-image * Recurring nightmares

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply)

* Emotional outbursts * Difficulty making decisions

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

* Excessive worry for 6 months * Restlessness * Need for reassurance

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)

* Family report of personality * Unaltered level of consciousness * Restlessness

The nurse who is assessing a client with PTSD would expect the client to report which of the following?

* Inability to relax * Increased alcohol consumption * Insomnia even when very fatigued * Suspicion of strangers

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury?

* Install childproof door locks * Place the client's mattress on the floor * Install light fixtures above the stairs

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply.)

* Respiratory distress * Retinal hemorrhage * Altered level of consciousness * Increase in head circumference

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply.)

* Round burn marks on forearm * Areas of exxhymosis on torso

A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply.)

* Sudden development of phobias * Increase level of anxiety during interview * Unwillingness to discuss the sexual assualt

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply.)

* Take breaks during the incident for food and water * Debrief with others following the incident * Take advantage of offered counseling

Interventions for clients with dementia that follow the psychosocial model of care include

* asking the clients about the place where they were born. * finding activities that engage the client's attention. * providing unrelated distractions when the client is agitated.

Examples of child maltreatment include

* calling the child stupid for climbing on a fence and getting injured. * spanking an infant who won't stop crying. * watching pornographic movies in a child's presence. * withholding meals as punishment for disobedience.

When assessing a client with delirium, the nurse will expect to see

* confusion. * impaired level of consciousness. * rapid onset of symptoms.

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?

Advise the client about the location of women's shelters.

Which of the following interventions is most appropriate in helping a client with early-stage dementia complete ADLs?

Allow enough time for the client to complete ADLs as independently as possible.

Which of the following statements about anger is true?

Anger results from being frustrated, hurt, or afraid

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

Assessing the client's risk for self-harm

Clients from other countries who suffered traumatic oppression in their native country may develop PTSD. Which of the following is least helpful in dealing with their PTSD?

Assimilating quickly into the culture of their current country of residence.

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

Attempt to reduce anxiety

Which of the following types of drugs requires cautious use with potentially aggressive clients?

Benzodiazepines

The nurse observes a client muttering to himself and pounding his fist in his other hand while pacing in the hallway. Which of the following principles should guide the nurse's action?

Clients who can verbalize angry feelings are less likely to become physically aggressive

Which of the following is the best action for the nurse to take when assessing a child who might be abused?

Consult with a professional member of the health team about making a report.

Behaviors observed during the recovery phase of the aggression cycle.

Decreased muscle tension Lowered voice volume Rational communication

A client with late moderate-stage dementia has been admitted to a long-term care facility. Which of the following nursing interventions will help the client to maintain optimal cognitive function?

Discuss pictures of children and grandchildren with the client.

Which type of child abuse can be most difficult to treat effectively?

Emotional

A client is pacing in the hallway with clenched fists and a flushed face. He is yelling and swearing. Which phase of the aggression cycle is he in?

Escalation

Which of the following might the nurse assess in a 3-year-old child with RAD?

Extreme resistance to social contact with parents and staff.

The nurse working with a client during a flashback says, "I know you're scared, but you're in a safe place. Do you see the bed in your room? Do you feel the chair you're sitting on?" The nurse is using which of the following techniques?

Grounding

A client with delirium is attempting to remove the intravenous tubing from his arm, saying to the nurse, "Get off me! Go away!" The client is experiencing which of the following?

Hallucinations

Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid?

If she tried to leave, she would be at increased risk for violence.

Which of the following assessment findings might indicate elder self-neglect?

Inability to manage personal finances

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

Intentionally causing an older adult to fall is an example of physical violence.

Which of the following interventions would be most helpful for a client with dissociative disorder having difficulty expressing feelings?

Journaling

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action?

Move the client away from others

When teaching a client about memantine (Namenda), the nurse will include which of the following?

Namenda can cause elevated blood pressure.

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take?

Provide information on resources for respite care

Which of the following is true about domestic violence between same-sex partners?

Rates of violence are about the same as between heterosexual partners.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?

Request that other staff members remain close by.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client and remain quiet.

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?

The client expresses a sense of unreality about the traumatic incident

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

The client states that the furniture in the room seems to be small and far away.

Which of the following is true about touching a client who is experiencing a flashback?

The nurse should touch the client only after receiving permission to do so.

Nursing interventions for hospitalized clients with PTSD include

Use of deep breathing and relaxation techniques.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

Work with the client on grounding techniques

The nurse is talking with a woman who is worried that her mother has Alzheimer's disease. The nurse knows that the first sign of dementia is

memory loss that is more than ordinary forgetfulness.