Psych Exam 3

Examples of Serious Mental Illness conditions include which of the following? A. Schizophrenia B. Major Depressive Disorder C. Acute Stress Disorder D. Bipolar Disorder E. Borderline Personality Disorder

A, B, D, E

Which is the priority action of the Sexual Assault Nurse Examiner? A. Talking with witnesses who accompanied the patient B. Gathering evidence from the patient C. Maintaining physiological stability of the patient D. Providing comfort and assurance to the patient

C Always the first step when dealing with patients of assault

A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that a child protective agency must be notified C. Show disapproval to the parent regarding the infant's condition D. Call at least 2 other staff members to sit in the room during the interview

B The nurse should tell the parent that a state protective agency must be notified of the infant's condition and explain the process to the parent.

A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions? A. Assign the client to a private room B. Ask the dietary department to provide the client with finger foods C. Place the client in 1-on-1 observation D. Keep the door closed to the client's room

C #1 method!! The nurse has both a legal and professional responsibility to provide a safe environment for this client who is at risk of suicide. A high risk of suicidal behavior requires constant 1-on-1 observation to ensure safety.

A nurse is creating a plan of care for a client who has Alzheimer's disease with moderate cognitive decline. Which of the following interventions should the nurse include to orient the client to the present? A. Discourage the client from reminiscing about the past. B. Overlook the client's frustration with communication. C. Talk with the client about scheduled daily activities. D. Present multiple options when offering the client choices.

C Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day. Encouraging the client to reminisce about the past can promote communication and serves as a reference point in time that can assist with orientation to the present. A client who has moderate Alzheimer's disease may experience frustration with communication. Overlooking the client's frustration is not therapeutic and can increase the client's anxiety level. Presenting one option at a time will help prevent the client from becoming overwhelmed and experiencing increased anxiety.

A nurse is teaching a newly licensed nurse about advanced directives. Which of the following statements by the newly licensed nurse indicates an understanding of this teaching? A. "Clients are required to complete an advance directive prior to discharge." B. "If the client has a health care proxy, he/she is no longer consulted for health care decisions." C. "I will assess the client's understanding of life-sustaining measures." D. "I will ask the next of kin if I should honor the client's advance directive."

C The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures in order to make informed decisions in advance directives.

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? A. Flat affect B. Refusal to accept help from others C. Report of intense guilt D. Denial of the sexual assault

C The nurse should expect a client who has rape-trauma syndrome to experience guilt about the sexual assault. These feelings of guilt can delay the healing process and produce a sustained and maladaptive response.

A nurse is caring for 4 clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention? A. A client who has generalized anxiety disorder and reports increased anxiety and insomnia B. A client who is expressing hopelessness during a crisis C. A client who is recovering from a crisis and asks for help in completing the recovery process D. A client who is having difficulty coping with stress and wants to learn relaxation techniques

C This client should receive tertiary care interventions such as a referral to community groups or facilities to complete recovery from a crisis. Tertiary care is designed to provide support for mental and physical healing after a crisis occurs.

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? A. "In what year did you graduate from high school?" B. "What is your favorite childhood memory?" C. "What did you have for supper yesterday?" D. "What is today's date?"

A When assessing a client's remote memory, the nurse should ask questions that determine the client's ability to remember things from the distant past. The nurse should ask questions that can be validated to ensure the information is correct.

A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? A. A. Chronic grief B. Uncomplicated grief C. Disenfranchised grief D. Delayed grief

C Disenfranchised grief occurs when social expectations restrict an individual's ability to cope with grief in an expected way. This type of grief can occur when the social relationship between the client and another individual cannot be openly recognized. As a result, the client does not have the social support that may be available to another individual who has an uncomplicated form of grief.

A home health nurse is providing teaching about respite care to the primary caregiver of a client with Alzheimer's disease. Which of the following pieces of information should the nurse include in this teaching? A. "Respite care refers to a community support group for family caregivers." B. "Respite care requires placing the client in an assisted living facility." C. "Respite care provides family members with temporary relief from caregiving." D. "Respite care involves daily assistance from a home health aide."

C Respite care services provide family caregivers with temporary relief from the tasks associated with caregiving for chronically ill family members, such as adults who have Alzheimer's disease or children who have complex medical or developmental needs. Caring for a client who has complex care needs in the home is a difficult and draining task. Respite care allows overwhelmed caregivers to leave the house, have some time away, or get an uninterrupted night of sleep.

A nurse in the emergency department is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and discharges the client. Which of the following actions should the nurse take? A. Request a social services consultation B. Contact the child's guardian to discuss the suspicion C. Report the provider's actions to the state medical board D. Report the suspected abuse to law enforcement

D Nurses are legally mandated to report suspected child and vulnerable adult abuse. The nurse should report the suspected child abuse to the appropriate agency of the state in which she is practicing.

A nurse is assessing a client who is at risk for cognitive impairment. Which of the following findings should the nurse identify as an early indication of cognitive decline? A. Disorientation to time B. Problems handling finances C. Social withdrawal D. Impaired recent memory

D Short-term memory loss is generally an early indication of mild cognitive decline. Other indications of early or mild dementia include misplacing household items and demonstrating subtle changes in personality.

A nurse admits a client to the emergency department with a fractured arm and periorbital ecchymosis. The nurse suspects intimate partner violence. Which of the following nursing interventions should the nurse take first? A. Notify the nursing supervisor B. Prepare the client for an X-ray C. Contact social services D. Check the client's injuries

D The first action the nurse should take using the nursing process is to assess the client. Medical, psychological stability.

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy

B A client who has end-stage cirrhosis likely has a life expectancy of ≤6 months. Therefore, this client is eligible for hospice services.

A nurse in a provider's office is assessing a client who is crying and states, "It's my child's first day of school." The nurse should recognize that the client is experiencing which of the following types of loss? A. Actual loss B. Maturational loss C. Perceived loss D. Situational loss

B A maturational loss is tied to a normal, expected life change (e.g. children going to school or an adult child moving out of state).

A nurse in a community mental health facility is caring for 4 clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis? A. A client who has a new diagnosis of severe bipolar disorder B. A client who is depressed following a devastating fire in her home C. A client who is experiencing acute grief following his father's death D. A client who is experiencing postpartum depression following the birth of her first child

B The nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or a crime of violence. Bipolar disorder is a chronic recurring mental illness. A client who develops a mental illness can experience a situational crisis, which is unanticipated and extraordinary. A client who is experiencing grief following the death of a family member is experiencing a maturational crisis, which occurs during different stages across the lifespan. A client who is experiencing postpartum depression following the birth of a child is experiencing a maturational crisis, which occurs during different stages across the lifespan.

A nurse is teaching the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."

B The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care.

A nurse is planning care for a client who has thoughts of suicide. Which of the following goals should the nurse include in the client's plan of care? A. The client will identify positive aspects of others. B. The client agrees to notify a staff member of thoughts of self-harm. C. The client will engage in an independent diversional activity. D. The client will not verbalize thoughts or feelings related to suicide.

B The nurse should instruct the client to notify a staff member if suicidal thoughts occur so that the client's needs are immediately addressed and actions are taken to prevent self-injury or suicide.

A nurse is caring for a client who has Alzheimer's disease. The client's adult son states the client has begun wandering away from her home. Which of the following responses should the nurse offer? A. "You should plan to move your mother into your home soon." B. "Place a complex lock at the top of each door that leads outside." C. "It is time to place your mother in a long-term care facility." D. "Have you reminded your mother about the dangers of wandering away from home?"

B The nurse should instruct the client's son to place complex locks at the top of doors that lead outside to prevent the client from wandering away from home. The nurse should also encourage the client's son to place a nonremovable medical alert bracelet on the client that includes the client's name, address, and telephone number.

A home health nurse is providing teaching for the family of a client who has moderate Alzheimer's disease. The family plans to care for the client in the home. Which of the following recommendations should the nurse include in the teaching? A. Place nonskid throw rugs over smooth floors B. Install locks at the tops of exterior doors C. Provide clothing that has zippers instead of buttons D. Encourage the client to take frequent naps during the day

B The nurse should instruct the family that the client is at an increased risk for wandering and getting lost. A safety intervention to decrease the risk for wandering is to install locks at the tops of exterior doors since the client who has moderate Alzheimer's disease loses the ability to reach and look upward.

A nurse is providing support for a client who is grieving the loss of her mother who died from Alzheimer's disease. Which of the following statements should the nurse make? A. "I know how you're feeling. I recently lost my father." B. "It must be very difficult for you to deal with your mother's death." C. "Hopefully, knowing your mother is in a better place provides you with some comfort." D. "I want you to let me know what I can do to help you cope with your mother's death."

B The nurse should use therapeutic communication when supporting a client who is grieving. This statement focuses the conversation on the client by acknowledging her grief and encourages further communication.

A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies to help reduce costs. Which of the following types of leadership is the nurse manager using? A. Autocratic B. Democratic C. Laissez-faire D. Moral

B This is an example of democratic leadership. A democratic leader guides staff toward an objective and shares responsibility with the staff. This is the ideal type of leadership in this situation because a great amount of creativity can occur, and many strategies can be developed.

A nurse in an acute care mental health facility is evaluating the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective? A. "I just don't want to talk about anything that happened before my admission." B. "I was feeling completely hopeless when I tried to kill myself." C. "I am feeling really great today, and I think I am ready to go home." D. "I want to punch the doctors who put me in this hospital."

B This statement should indicate to the nurse that the client is meeting a short-term goal of being willing to discuss painful feelings that occurred at the time of the suicide attempt. The nurse should also evaluate whether the client is now willing to seek help when feelings of self-harm occur. The client's unwillingness to talk about feelings or about previous occurrences, including the suicide attempt, should indicate to the nurse that goals to prevent further suicide attempts have not yet been met. This statement might indicate an emotional change from depression to happiness, which can be an indication that the client has decided to complete suicide and is feeling happy about that decision. It does not indicate that the client has increased coping skills or understands how to prevent suicidal thoughts. The nurse should continue to monitor the client carefully after hearing this statement. This statement indicates the client is angry about being unable to carry out plans for self-harm. The client is also demonstrating blame toward the providers for the admission to the facility. This statement does not indicate that the client has increased coping skills or understands what to do to prevent suicidal thoughts.

A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members B. Spending time alone C. Giving away possessions D. Excessive crying

C Giving away possessions indicates the greatest risk for suicide. The nurse should have a relationship with the adolescent built upon trust and respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse is caring for a client who was newly diagnosed with breast cancer that has metastasized into the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kübler-Ross' grief theory? A. Anger B. Bargaining C. Denial D. Depression

C Kübler-Ross worked with terminally ill clients and developed a set of responses that are common to clients who are experiencing a loss such as a diagnosis of terminal illness. During the first stage, denial and refusal to accept the imminence of the loss are self-protection mechanisms that allow the client time to process the diagnosis. During this stage, the client has difficulty accepting the loss or diagnosis and might refuse to discuss the impending or actual loss during this stage. The client might also be convinced that a mistake has been made and that there is no loss.

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility

C Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance. A. Rehabilitation programs help clients return to optimal functioning after an illness or injury. However, severe dementia will not improve with rehabilitative services. B. An assisted living facility provides independence for clients who need only limited personal care. A client who has severe dementia needs total care. D. Although adult day care facilities do help family caregivers maintain some aspects of their lifestyle and independence, these facilities provide care and supervision for clients who need minimal assistance (e.g. taking medication, receiving physical therapy, or receiving counseling). They do not provide care for clients who have severe dementia.

A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide? A. "Everything will be better soon." B. "Soon, no one will have to worry about me." C. "There's no point in living any longer." D. "I want to donate my organs to help others."

C The nurse should identify this client comment as an overt statement about the client's risk of suicide. The nurse should assess the client's suicidal ideation further and implement interventions to promote safety. The other answers identify as covert statements.

A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing these injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? A. "Aren't you worried about the safety of your children?" B. "Can you identify which of your behaviors provoke your partner?" C. "The next time this occurs, what could you do to ensure your safety?" D. "You need to remove yourself and your children from an abusive situation."

C The nurse should use the therapeutic communication technique of encouraging the formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan and include information about shelters if the client chooses to leave in the future.

A nurse is admitting a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first? A. Assess the client's level of self-esteem B. Document the client's mood and affect C. Attend an interdisciplinary team meeting D. Search the client's belongings

D The greatest risk to this client is self-injury from another suicide attempt; therefore, the nurse should first search the client's belongings to ensure there are no items that the client could use to harm herself.

A nurse is caring for a client who is confused and wanders at night. The nurse asks the nurse manager if the client can be placed in physical restraints at bedtime. Which of the following responses should the nurse manager make? A. "Restraints can be used if the client is having verbal outbursts." B. "Restraints have been effective in reducing the number of client falls." C. "Restraints can be applied only when the unit manager approves of their use." D. "Restraining the client can increase confusion."

D The nurse manager should identify that restraining a confused client can worsen the confusion. The nurse should use other methods to prevent wandering, such as diversional activities, reducing stimulation, and administering a PRN medication.

A nurse is caring for a client who has borderline personality disorder. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. After providing first aid, which of the following actions should the nurse perform? A. Encourage the client to discuss feelings about his self-injurious behavior during group therapy B. Fill out an incident report for risk management about the client's self-injurious behavior C. Document the client's self-injurious behavior in his medical record D. Identify the client's feelings that led to self-injurious behavior

D The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assist the client in identifying events or feelings that led to his self-injurious behavior.

A nurse is assessing the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

D The nurse should assess the lethality of a client's suicide plan and identify the method as hard or soft. Ingesting antidepressants or other pills is considered a soft method due to the lower risk of resulting in death. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun. (hardest method = least available to get help/ rescue) (lowest method = most available for rescue)

A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? A. The client requires assistance with eating. B. The client independently manages personal finances. C. The client has bladder incontinence. D. The client is able to identify the names of family members.

D The nurse should expect this client who has Stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until Stage 6. A client with Stage 4 Alzheimer's disease will still have the ability to eat without assistance. Clients who have Alzheimer's disease maintain this ability until Stage 7. A client with Stage 4 Alzheimer's disease will have difficulty performing complex tasks such as managing personal finances. A client with Stage 4 Alzheimer's disease will be able to use the toilet independently. Clients who have Alzheimer's disease maintain continence until Stage 6.

A nurse is providing teaching to a family member of a client who has dementia. Which of the following statements should the nurse include? A. "Dementia is often associated with a reaction to a new medication." B. "Dementia is usually reversible with prompt treatment." C. "Dementia develops rapidly over a matter of hours or days." D. "Dementia is commonly associated with Alzheimer's disease."

D The nurse should identify the common causes of dementia, which include Alzheimer's disease, chronic alcohol use disorder, diseases affecting the neurological and vascular systems, and head trauma. Reaction to medications are more-so signs of delirium. Delirium is reversible. Dementia develops slowly over months-years.

A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? A. "Last night my partner beat me worse than ever before." B. "It'll be easier just to make my partner mad and get the violence over with." C. "I believe my partner is remorseful and won't hurt me again." D. "I only got shoved a little bit, and it was my fault for coming home late."

D The nurse should identify this statement as an indication of the tension-building phase of the cycle of violence. During this phase, episodes of violence are often minor, and the recipient might rationalize the episodes by accepting blame. A. This is an indication of the acute battering phase. During this phase, the tension reaches a peak, and serious violence occurs. B. This is an indication of the acute battering phase. During this phase, the tension can become so increased that the recipient of the violence might provoke the abuser in order to get the violence over with. C. This is an indication of the honeymoon phase. During this phase, the abuser is remorseful and makes promises not to inflict violence again. The recipient of the violence often believes these professions, and the cycle continues.

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation? A. "I don't want to be alive any longer." B. "I think every day about killing myself." C. "My parents will be happier when I'm dead." D. "I won't have to deal with things much longer."

D The nurse should listen closely for overt and covert statements that indicate a client's intent to commit suicide. Covert statements, such as this example, can implicate a client's plan for suicide or wish not to be alive. Covert statements are more difficult to identify because they do not openly express the client's suicidal thoughts. The nurse should assess the client further for suicidal ideation and implement interventions to reduce the risk of a suicide attempt. The other statements are overt.

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? A. Obtain a PRN prescription for restraints from the client's provider. B. Visually observe the client every 10 min until restraints are removed. C. Ensure 3 fingers can fit between the restraint and the client's wrist. D. Document the client's behavior every 15 min while restraints are in place.

D The nurse should plan to document the client's behavior every 15 min while restraints are in place to meet the legal requirement for use of restraints. This documentation allows prompt identification of complications related to restraint use and helps ensure that restraints are removed as soon as possible, depending on the client's behavior. A. The nurse should obtain a prescription for restraints from the provider; however, this prescription is legally required to be current and specific to the client's present needs rather than PRN. B. The nurse should plan for one-on-one observation by staff while the client is in restraints. C. The nurse should ensure 2 fingers can fit between the restraints and the client's wrist. This safety check promotes adequate circulation while maintaining the effectiveness of the restraint.

A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates an understanding of teaching? A. "I will do my best to try to get him to eat something." B. "I will lay him flat if his breathing becomes shallow." C. "I will use an electric blanket to keep him warm." D. "I will continue to talk to him, even when he's sleeping."

D The nurse should reinforce to the partner that the client's hearing is thought to be the last sense to leave during the dying process. Therefore, continue to communicate softly with the client.

A new nurse manager on a busy oncology unit keeps her door closed when she is in the office and does not offer to help resolve daily staffing issues. Which of the following types of leadership behavior is this nurse manager displaying? A. Transformational B. Democratic C. Autocratic D. Laissez-faire

D This nurse manager is a laissez-faire leader, providing little support or guidance. The leader's activity is minimal and contributes to reduced staff efficiency. B. A democratic leader acts as a facilitator and resource person and maintains a moderate degree of control among group members. C. An autocratic leader is controlling and makes all of the decisions. This type of leader maintains a high degree of control and allows little freedom among group members.

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client states, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly. You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like to wash your hair?" D. "Would you like to talk about why you feel this way?"

D This response by the nurse acknowledges the client's feelings and conveys an ability to understand them, which promotes a trusting relationship between the client and nurse.

A home hospice nurse is caring for a client who is dying. A family member of the client is talking to the nurse. Which of the following statements by the family member requires clarification by the nurse? A. "Although my father can't get around very much, at least he is alert." B. "My siblings and I have a schedule of when we are available to provide care for our father." C. "My biggest concern is that I don't want my father to be in any pain." D. "I'm glad that professionals will be here in case my father stops breathing."

D This statement will require clarification for two reasons. First, when a client is admitted to hospice, the care changes from curative to palliative. Hospice clients do not receive major medical interventions or resuscitative measures to prolong life like CPR. The nurse needs to determine if the family member understands and accepts the goals of hospice care. Second, home hospice care is provided primarily by family and volunteers. The nurse makes frequent visits to evaluate the client and provide support and education to the client's primary caregivers, and assistive personnel might assist with the client's ADL needs; however, a professional health care provider is not always in the client's home.

A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements should indicate that the AP requires further teaching? A. "We will be serving breakfast in 10 min. I will stay here while you get ready." B. "It's Monday morning. I know that your favorite television shows are on this evening." C. "I see that you have a new photo on the wall. Can you tell me who that girl is?" D. "It's almost time for your appointment. Let me do your hair for you and brush your teeth."

D When a client with dementia has periods of confusion, the AP should give the client additional time to complete activities that can be performed independently. Insisting on completing the task or attempting to hurry the client can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or truly needs it.

A nurse in a long-term care facility is caring for a client who has dementia and becomes increasingly agitated in the afternoon. Which of the following actions should the nurse take first? A. Place the client in a private room B. Apply soft wrist restraints on the client C. Administer haloperidol to the client D. Offer diversionary activities for the client

D When providing client care, the nurse should use the least restrictive intervention first; therefore, the nurse should offer activities to distract the client and redirect agitation and energy to behaviors that might calm the client.

A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? A. Progressive deterioration of cognitive function B. Rapid fluctuation in level of consciousness C. Loss of language ability D. Absence of contributing factors to pinpoint the cause of delirium

B A rapidly fluctuating level of consciousness is an expected finding for a client who has acute delirium. Progressive deterioration of cognitive function and loss of language ability are expected findings for a client who has dementia. Contributing factors that cause delirium are sometimes multifactorial. The nurse should help assess the client who has delirium for an underlying cause of the problem. Infection, substance withdrawal, head injury, and pain are common causes of acute delirium.

A nurse delegates a licensed practical nurse (LPN) to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the LPN should indicate to the nurse that she requires further teaching? A. Accompanying the client to physical and occupational therapy B. Ambulating the client's roommate while the client sleeps C. Asking the nurse at lunchtime to assign another LPN to perform this task until her return D. Remaining with the client while family members are visiting

B One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injurious behavior while the LPN is caring for the other client.

A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, "I feel numb and can't believe this is happening to us." Which of the following interventions by the nurse is the first priority? A. Explore effective ways of family coping B. Encourage the family's expression of their feelings C. Discuss the disease and its manifestations with family members D. Instruct the family about anticipatory grieving

B The first action the nurse should take using the nursing process is to assess the family by encouraging them to express their feelings about their child's illness. This assessment will allow the nurse to understand the particular needs of the family better as they prepare to face their child's death.

A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority when planning care for this client? A. Promoting and maintaining client safety B. Discussing reasons for the client's behavior C. Helping the client recognize feelings D. Teaching the client alternative coping strategies

A A client who has self-inflicted injuries is at risk for further self-harm or suicide; therefore, the client's safety is the priority. The nurse should apply the safety and risk-reduction priority-setting framework when planning care for this client, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? A. Talk to the client from 2 arm-lengths away B. Obtain assistance to restrain the client for safety C. Firmly state to the client that morning care will be performed D. Call the provider to request a prescription for an antipsychotic medication

A The nurse should talk calmly and quietly to the client to decrease agitation. The nurse should remain 1 to 2 arm-lengths away to provide a sense of personal space and maintain safety if the client becomes aggressive. The client's refusal of care is not a justification for restraints. The nurse should apply restraints only if the client's behavior becomes a threat to the safety of self or others.The client has a right to refuse care. Stating that care will be performed despite refusal can increase the client's anxiety and agitation. Antipsychotic medications are used only with extreme caution due to the increased risk of death for clients who have Alzheimer's disease. Antipsychotic medications are not indicated for the treatment of agitation.

A nurse at a long-term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? A. Encourage the client to make choices about meals and activities B. Use written signs to label specific rooms C. Post a large calendar on the bulletin board D. Place an electronic wander alert bracelet on the client's wrist

C Posting a large calendar in a central location will assist this client with orientation. Encouraging the client to make several choices can increase the client's level of anxiety. Labeling specific rooms with symbols can help decrease the client's confusion. Placing an electronic alarm bracelet is an appropriate intervention to promote client safety; however, it will not assist this client with orientation.

Which areas of nursing are you most likely to encounter violence from patients? Select all that apply. A. Emergency Room B. Elderly Care Facilities C. Pediatric Centers D. Mental Health Facilities

A, B, D These 3 and in the intensive care units.

Which of the following are phases in the Cycle of Violence A. Acute battering phase B. Recovery phase C. Acceptance phase D. Honeymoon phase E. Tension building phase

A, D, E

Who is often the perpetrator of violence against children? A. Care takers B. Peers C. Violent strangers D. Teachers

A

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence. B. The client expresses anger over the loss. C. This is the client's first experience of the loss of a family member. D. The client demonstrates reorganization of behavior.

A When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or to say goodbye.

A woman was involved in a motor vehicle accident on her way to work. Which type of crisis does this represent? A. Adventitious B. Situational C. MaturationaL D. Unplanned

B

Which of the following actions is in alignment with the working phase of group therapy? A. Planning the rules of the group B. Discussing and processing feeling, beliefs and perceptions C. Reviewing HIPPA guidelines D. Summarizing new skills learned during sessions

B A - orientation C - planning? D - termination/ evaluation

A nurse is speaking with the family member of a client who has early Alzheimer's disease. The family member would like to keep the client living at home, but the client requires assistance while the family member is away at work. Which of the following services should the nurse include in the discussion? A. Hospice care B. Adult day care C. Assisted-living facility D. Long-term care facility

B Adult day care personnel can provide constant assistance with ADLs while the family member is at work; the client can live at home during the night and evening hours.

A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make? A. "Tell me how everyone wants to hurt you." B. "You must feel very frightened to think someone wants to hurt you." C. "No one here wants to kill you." D. "Who in particular do you think wants to kill you?"

B The nurse should acknowledge the client's feelings about the delusion, which helps the client feel safe and accepted.

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? A. Ask the client what she believes she did to deserve being physically abused B. Avoid documenting subjective verbatim statements from the client regarding injuries C. Talk to the client about making a safety plan D. Explain the cycle of violence to the client

C

What must the nurse consider when determining if a patient has age related memory loss verses neurocognitive impairment? A. The importance of the event that needs to be remembered B. If the patient is aware they are forgetting things C. If the patient is forgetting things that affects their ability to function D. If the family members are reporting the patient is forgetting important events

C

Onset is unlikely for which of the following mental health conditions in elderly patients? SATA A. Anxiety B. Depression C. Schizophrenia D. Alzheimer's E. Delirium F. ADHD

C, F

Several patients are receiving treatment on an inpatient psychiatric unit. Which patient would require one-to-one monitoring? A. A patient whose self-harm plan includes running out in front of a train B. A patient whose self-harm plan includes holding their breath until they suffocate C. A patient whose self-harm plan includes overdosing on their medications D. A patient whose self-harm plan includes banging their head against the door frames

D

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

D A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

A nurse is caring for a client who has delirium. Which of the following items should the nurse use to promote optimal cognitive function for this client? A. Identification bracelet B. Menu for the cafeteria C. Map of the facility D. Wall calendar

D A wall calendar can offer a client who is experiencing delirium environmental cues for reorientation and memory.

A nurse is planning care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse include in the client's plan of care? A. Search the client and his belongings upon arrival. B. Assign the client to a private room near the nurses' station. C. Instruct an assistive personnel to check on the client every 15 min. D. Keep the door to the client's room closed.

A The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the client's risk for injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers.

A nurse is organizing a therapeutic support group for individuals who have bulimia nervosa. Which of the following tasks should the nurse plan to include during the orientation phase of group development? A. Determine the rules that the group will follow B. Address disagreements among group members C. Help clients work through the grief response D. Transition from the role of leader to facilitator

A During the orientation phase of group development, the nurse should determine the rules that apply to the group and ensure that all members understand these rules. Examples of rules to be discussed include confidentiality and meeting times. B. The nurse should address disagreements among group members during the working phase of group development. C. The nurse should expect clients to experience a grief response during the termination phase of group development. D. The nurse should transition from the role of group leader to group facilitator during the working phase of group development.

A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first? A. Denial B. Bargaining C. Anger D. Depression

A Evidenced-based practice indicates the nurse should first expect the parents to experience denial. Denial is followed by anger, bargaining, depression, and finally acceptance.

A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now." Which of the following actions should the nurse take? A. Talk to the client about available community resources B. Distract the client by discussing events not related to the crisis C. Reassure the client that he will feel better soon D. Give the client advice about what to do during the next few days

A Initial steps should be taken to make a client who is experiencing a crisis feel safe and less anxious. The priority for the nurse is to ensure the client is safe, which includes assessing any thoughts of self-harm. After promoting client safety, the nurse should let the client know what personal and community resources are available. The nurse should determine the client's perception of the crisis, availability of support, and ability to cope with the crisis.

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kübler-Ross' stages of grief? A. "I would give anything to live to see my grandchild born." B. "Can you make sure there hasn't been a mistake with my test results?" C. "I feel so sad that I will be leaving my partner all alone." D. "What have I done to deserve this death sentence?"

A Kübler-Ross identified common responses of clients who experience any form of loss. These responses are divided into 5 stages. While each of these stages is experienced by clients, they are not necessarily experienced in a linear fashion or in the exact same order. Some clients can experience a stage more than once. This response shows that the client is in the bargaining stage and might be trying to make a deal with a higher power to prolong life.

A nurse is preparing an in-service session about Alzheimer's disease for a group of newly licensed nurses. Which of the following findings should the nurse include as an early manifestation in the progression of the disease? A. Forgetting material that was just read B. Losing the ability to feel emotions C. Experiencing changes in physical abilities such as swallowing D. Having difficulty controlling the bladder

A Short-term memory loss. Forgetting material that has just been read is a sign of mild Alzheimer's and is an early manifestation of the disease. Mild memory impairment includes recent memory. Gradually, deterioration progresses to include both recent and remote memory.

A nurse is assessing a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?" Which of the following questions is the nurse's priority? A. "Are you thinking about hurting yourself?" B. "Do you have someone who could come here to be with you?" C. "How will this situation affect your life?" D. "What qualities have helped you cope with a crisis in the past?"

A The client's statement and current emotional state indicate that the client's greatest risk is for self-harm. Therefore, the priority for the nurse is to ask the client about the possibility of suicide or self-harm.

A nurse is caring for a client who presents with a fractured wrist. The nurse suspects intimate partner violence. Which of the following interventions is the nurse's priority? A. Help the client develop a safety plan B. Teach the client empowerment skills C. Provide information about a support group for intimate partner abuse D. Make a follow-up appointment with the primary provider

A The greatest risk to this client is further injury from the partner; therefore, the priority intervention for the nurse is to help the client develop a safety plan for a rapid escape if further violence occurs.

A nurse is teaching a parent who has admitted to verbally abusing his children about stress management techniques. Which of the following strategies is the nurse providing? A. Tertiary prevention B. Individual psychotherapy C. Family psychotherapy D. Primary prevention

A The nurse is providing tertiary prevention methods by offering stress management techniques to the abuser after the abuse has occurred. Tertiary prevention methods facilitate the rehabilitative process for both victims of violence and those who perpetuate it.

A nurse is caring for a client who is dying. The client's son appears visibly upset when he visits. Which of the following statements should the nurse make to the client's son? A. "Tell me how you're feeling about your mother's illness." B. "Consider bringing a support person when you visit your mother." C. "It is okay to feel angry when losing someone close to you." D. "You should think about joining a grief support group."

A The nurse is using a therapeutic communication technique of offering a general lead to allow the son to express his feelings. This statement indicates that the nurse is interested in not only the client but also the client's family.

A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis

A The nurse should determine whether the client has thoughts of self-harm following a sexual assault or other crisis situations. The nurse's priority is to ensure the client's safety.

A nurse working in a retirement community is assessing an older adult client. Which of the following manifestations should the nurse identify as an expected age-related change? A. Making occasional errors when balancing a checkbook B. Confusion with time or place C. Poor judgment D. Changes in mood

A The nurse should identify that making occasional errors when balancing a checkbook is an expected age-related change in an older adult. Other manifestations can include needing occasional assistance with operating appliances, forgetting a name or an appointment and then remembering it later, difficulty finding the correct use of a word, and becoming tired after social activities. The nurse should identify that confusion with time or place is a manifestation of dementia. Other manifestations can include memory loss that disrupts daily living, poor judgment, and changes in mood and personality. This is not an example of an expected age-related change for an older adult client.

A nurse is planning care for a client with borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take? A. Restrict participation in group therapy sessions. B. Establish consequences for self-mutilation. C. Maintain close observation of the client. D. Provide an unstructured environment.

C Clients who have borderline personality disorder are at risk of self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury.

A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? A. "Yesterday, my partner put on a jacket upside down." B. "My partner has trouble reading the newspaper." C. "My partner often repeats words." D. "Last week, my partner did not recognize the sound of the alarm clock."

A The nurse should recognize that this statement is an indication that the client is experiencing apraxia (the lack of ability to accomplish once known tasks). This manifestation is considered a cognitive deficit because there is no loss of motor or sensory ability.

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A. Request a prescription for an antianxiety medication B. Provide the client with a stimulating activity prior to bedtime C. Dim the lights in the client's room at night D. Encourage the client to make decisions about her daily routine

A The nurse should request a prescription for an antianxiety medication for a client who develops delirium. Administration of a PRN antianxiety medication can decrease anxiety and agitation.

What mental health disturbance is likely to occur after a 40 year old patient is sexually assault? Select all that apply. A. Depression B. Anxiety C. PTSD D. Schizophrenia

A, B, C (schizophrenia is not a comorbidity for assault, also it should not onset in the older population)

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception

B Impaired judgment occurs in clients who have dementia as they lose their ability to reason, think abstractly, and have rational thoughts. Altered LOC and rapid change in personality are findings of delirium. Disturbance in perception is a finding of psychosis.

A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that the group requires further teaching when a member identifies which of the following findings as a manifestation of Alzheimer's disease? A. Impaired judgment B. Sudden confusion C. Personality change D. Remote memory loss

B The nurse should clarify that a client who has Alzheimer's disease is expected to exhibit confusion that develops slowly over months. Clients who have delirium exhibit sudden confusion. All other answer choices are findings of Alzheimers.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A. Assign the client several tasks at the same time B. Maintain a low-stimulation environment C. Advise family to visit frequently as a group D. Encourage the client to make choices regarding care

B To minimize confusion and anxiety, the nurse should maintain a low-stimulation environment for a client who has dementia.

How would you know a patient has moderate stage symptoms of of Alzheimer's disease and not Delirium? Select all that apply. A. Rapid onset of disease process B. Slow onset of disease process C. Short term memory loss D. Long term memory loss E. Use of confabulation

B, C, E

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C During the stage of depression, the client has realized the full impact of the loss or impending death and might express hopelessness and despair.

A home health nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse why the client becomes disoriented, confused, and often combative later in the day. Which of the following conditions should the nurse plan to report to the provider? A. Electrolyte imbalance B. Hypothyroidism C. Sundowning D. Adverse effect of medication

C Sundowning, an increase in confusion beginning in the afternoon and lasting into the night, is a common manifestation of Alzheimer's disease. The client can become confused, aggressive, agitated, and obsessive, leading to severe disorientation.

A nurse is caring for a client whose adolescent child just died in a motor-vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take? A. Suggest that the client call the facility's chaplain B. Provide a quiet place for the client to be alone C. Stay with the client and allow the client to cry D. Express sympathy for the client's loss

C The nurse demonstrates respect for the client's feelings by staying nearby. The use of silence is a therapeutic communication technique, and allowing the client to cry is therapeutic during times of grieving.

A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? A. Avoid directly asking the client if she has been abused B. Use a confrontational approach C. Maintain a nonjudgmental tone D. Avoid being in the room alone with the client

C The nurse should use a nonjudgmental tone to promote trust and communication.

A home health nurse is assessing a client who has advanced dementia and whose caretaker recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse make a referral for this client? A. Partial hospitalization B. Adult day care facility C. Inpatient geropsychiatric unit D. Long-term care nursing center

D A long-term care nursing center provides intermediate or custodial care for clients who have acute or chronic illnesses. A client who has advanced dementia is a candidate for a skilled nursing facility because the client needs 24-hour nursing care and support.

A nurse is caring for an older adult client who has a terminal illness. The client tells the nurse, "I just want to live 1 more month so I can see my grandchild get married." Which of the following Kübler-Ross stages of grief is this client experiencing? A. Depression B. Acceptance C. Denial D. Bargaining

D Bargaining is the third stage of grief, according to Kübler-Ross. Bargaining represents the last effort at overcoming death by earning longer life. Trying to put off death for a last major celebration in the client's life (e.g. the marriage of a grandchild) is a form of bargaining.

A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following should the nurse include as the purpose of palliative care? A. Curing the disease B. Producing remission C. Hastening death D. Providing comfort measures

D Palliative care is an approach to care that promotes comfort for a client who has a terminal diagnosis and is not receiving aggressive therapy. Palliative care focuses on managing manifestations of the disease, not on curing the disease.

A nurse is caring for a client with dementia who paces during meals. Which of the following actions should the nurse take? A. Restrain the client during meals B. Provide a large meal to the client at bedtime C. Administer an antipsychotic medication D. Provide finger foods to the client

D The nurse should provide finger foods to encourage increased intake throughout the day and to improve the client's nutritional status.