Test 4 practice Questions

The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine which action is the priority at this time? 1 - Providing the other clients on the unit with a sense of comfort and safety 2- Providing a safe place for the client to pace that is away from the other clients 3 - Offering the client a less stimulating area in which to calm down and gain control 4 - Assisting in caring for the client in a controlled environment, such as a quiet room

Providing a safe place for the client to pace that is away from the other clients

A female victim of 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? 1 - You need to try to be realistic. The rape did not just occur 2 - It will take some time to get over these feelings about your rape 3 - Tell me more about the incident that caused you to feel like the rape just occurred 4- What do you think that you can do to alleviate some fo your fears about being raped again?

Tell me more about the incident that caused you to feel like the rape just occurred

A client admitted to the mental health unit after attacking his father for disturbing him at his computer interrupts the nurse during morning rounds and says "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact? 1 - I will be back to talk with you in 15 minutes after i complete nursing rounds 2- You hurt your father and you wont leave here until you can control yourself better 3 -You have a project to save the world? I'd really like to hear about that after I finish rounds 4 -Well, sit right down and eat your breakfast. Your not going to save the world on an empty stomach

I will be back to talk with you in 15 minutes after i complete nursing rounds

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1 -Information regarding shelters 2 - Instructions regarding calling the police 3 - Instructions regarding self defense classes 4 - Instructions explaining the importance of leaving the violent situation

Information regarding shelters

When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? 1- Administered medication has taken effect 2- The client verbalizes the reasons for the violent behavior 3- The client apologizes and tells the nurse that it will never happen again 4- No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints

No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's priority? 1 - Provide safety for the client and other clients on the unit 2 - Provide the clients on the unit with a sense of comfort and safety 3 - Assist the staff in caring for the client in a controlled environment 4 - Offer the client a less stimulating area in which to calm down and gain control

Provide safety for the client and other clients on the unit

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1 - Begin to teach relaxation techniques 2 -Encourage the client to discuss the assault 3 - Remain with the client until the anxiety decreases 4 - Place the client in a quiet room alone to decrease stimulation

Remain with the client until the anxiety decreases

During a group session, a client threatens to "punch every one of you" which is the appropriate initial nursing action? 1 - Call security to come to the session immediately 2 - Require the client to leave the group immediately 3 - Remind the client that punching anyone is a reason for being placed into seclusion 4 - Remind the client that talking about personal anger is appropriate, but acting on it is not

Remind the client that talking about personal anger is appropriate, but acting on it is not

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1- Adhering to the mandatory abuse reporting laws 2- Notifying the caseworker of the family situation 3- Removing the client from any immediate danger 4- Obtaining treatment for the abusing family member

Removing the client from any immediate danger

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? 1 - What is causing you to behave so agitated? 2 - Why are you intent on upsetting the other clients ? 3 - Please stop so I don't have to put you in sedation 4 - You are going to be restrained if you do not change your behavior

What is causing you to behave so agitated?

The nurse is assigned to care for a chemically dependent client who has this potential for violent episodes. In planning care for the client, which action by the nurse should receive priority? 1- Speaks slowly to the client 2- Projects an attitude of calmness 3- Bargains to prevent the violent episodes 4- Moves quietly when approaching the client

Projects an attitude of calmness

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? 1- Signs of depression 2- Reactions to a devastating event 3- Evidence that the client t is a high suicide risk 4- Indicative of the need for hospital admission

Reactions to a devastating event

The nurse observes that a client with the potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures that other clients. Which statement would be most appropriate to make to this client? 1- You need to stop that behavior now 2 - You will need to be placed in seclusion 3 - You seem restless, tell me what's happening 4 - You will need to be restrained if you do not change your behavior

You seem restless, tell me what's happening

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow up? 1 - Reddened sclera of the eyes 2 - Dry flaking of the scalp 3 - A reddish purple mark on the neck 4 - A scaly rash noted on the elbows and knees

A reddish purple mark on the neck

During a support group session, a client says "My husband hit me alot, 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? 1 - Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what she's feeling? 2- Yes. Everyone here was ill used and abused, but what makes you think that is a reason to stab someone? 3 - Everyone agreed that you couldn't let him hurt your children. But is there anything you would do differently? 4 - Your story is very much like every woman here. The problem is getting a jury to see that you were justified in stabbing him

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? 1.) Abusers use fear and intimidation 2.) Abusers usually have poor self esteem 3.) Abusers often are jealous or self centered 4.) Abusers are more often from low income families

Abusers are more often from low income families

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. 1 - Initiate confinement measures 2 - Acknowledge the clients behavior 3 - Assist the client to an area that is quiet 4 - Maintain a safe distance from the client 5 - Allow the client to take control of the situation

Acknowledge the clients behavior Assist the client to an area that is quiet Maintain a safe distance from the client

when planning care for a client with a history of violent behavior towards others, the nurse should include which interventions? 1- Providing complete privacy when caring for the client 2 - Admitting the client to a room near the nurses station 3 - Avoiding eye contact with the client while providing nursing care 4 - Arranging for a security officer to be nearby and available but out of the clients site 5 - Closing the door to the clients room to ensure privacy when providing direct client care

Admitting the client to a room near the nurses station Arranging for a security officer to be nearby and available but out of the clients site

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow up because it could potentially present a danger to the client, health care providers, and others on the nursing unit. 1 - Facing the client when providing care 2 - Assigning the client to a room at the end of the hall 3 - Ensuring that a security officer is available at all times if needed 4- Keeping the door to the clients room open when providing care to the client

Assigning the client to a room at the end of the hall

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement ? 1.) Place the client in seclusion for 30 minutes 2.) Tell the client that the behavior is inappropriate 3.) Escort the client to their room, with the assistance of other staff 4.) Tell the client that their telephone privileges are revoked for 24 hrs

Escort the client to their room, with the assistance of other staff

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 milleu? 1- Inform the client that the behavior is unacceptable 2- Offer to assist the client to an examination room until the psychiatrist is notified 3- Assure the client that the psychiatrist will be called as soon as the report is completed 4- Tell the client to wait in his room, and inform him that a nurse will come when the report is finished

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