323 NCLEX Qs EXAM 3

A client being seen in the ED immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? A. Denial B. Projection C. Rationalization D. Intellectualization

A. Denial

The ED nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? A. Information regarding shelters B. Instructions regarding calling the police C. Instructions regarding self-defense classes D. Explaining the importance of leaving the violent situation

A. Information regarding shelters

A client is preparing to attend an AA meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? A. Admitting to having a problem B. Substituting other activities for drinking C. Stating that the drinking will be stopped D. Discontinuing relationships with people who drink

A. Admitting to having a problem

A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic- nurse-client relationship? A. Trusting B. Working C. Orientation D. Termination

D. Termination

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SELECT ALL A. Communicate expected behaviors to the client B. Ensure that the client know that they are not in charge of the nursing unit C. Assist the client in identifying ways of setting limits on personal behaviors D. Follow through about the consequences of behavior in a non punitive manner E. Enforce rules by informing the client that they will not be allowed to attend group therapies F. Have the client state the consequences for behaving in ways that are viewed as unacceptable

A. Communicate expected behaviors to the client C. Assist the client in identifying ways of setting limits on personal behaviors D. Follow through about the consequences of behavior in a non punitive manner F. Have the client state the consequences for behaving in ways that are viewed as unacceptable

The nurse determines that the wife of an alcoholic client is benefiting from attending an AA group if the nurse hears the wife make which statement? A. I no longer feel that I deserve the beatings my husband inflicts on me B. My attendance at the meetings has helped me to see that I provoke my husband's violence C. I enjoy attending the meetings because they get me out of the house and away from my husband D. I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics

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

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SELECT ALL A. Monitor vitals B. Maintain NPO status C. Provide a safe environment D. Address hallucinations therapeutically E. Provide stimulation in the environment F. Provide reality orientation as appropriate

A. Monitor vitals C. Provide a safe environment D. Address hallucinations therapeutically F. Provide reality orientation as appropriate

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? A. Ask the client why he started taking illegal drugs B. Ask the client about the amount of drugs used and its effect C. Ask the client how long he thought that he could take drugs without someone finding out D. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home

B. Ask the client about the amount of drugs used and its effect

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? A. Witnessing a murder B. Death of a loved one C. A fire that destroyed the client's home D. A recent rape episode experienced by the client

B. Death of a loved one

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of PTSD? SELECT ALL A. Im afraid of spiders B. I keep reliving the robbery C. I see his face everywhere I go D. I don't want anything to eat now E. I might have died over a few dollars in my pocket F. I have to wash my hands over and over again many times

B. I keep reliving the robbery C. I see his face everywhere I go E. I might have died over a few dollars in my pocket

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? A. Signs of depression B. Normal reactions to a devastating event C. Evidence that the client is at high risk for suicide D. Indicative of the need for hospital admission

B. Normal reactions to a devastating event

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 happened yesterday, even though it has been a few months since the incident. What is the most appropriate nursing response? A. You need to try and be realistic. The rape did not just occur B. It will take some time to get over those feelings about your rape C. Tell me more about the incident that causes you to feel like the rape just occurred D. What do you think that you can do to alleviate some of your fears about being raped again?

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

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand temors, lethargy D. Hypertension, changes in LOC, hallucinations

D. Hypertension, changes in LOC, hallucinations