Pysch Exam 5

A nurse Is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority? a. Reviewing the client's toxicology laboratory report b. Making a contract with the client for eating behavior c. Initiating suicide precautions d. Administering the Hamilton Depression Scale

c. Initiating suicide precautions

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take? a. Place metal utensils on the client's meal tray. b. Assign the client to a private room c. Inspect the client's personal belongings. d. Tuck bedcovers over client's hands and arms

c. Inspect the client's personal belongings.

A client who has bipolar disorder approaches the nurse and reveals fresh. self-inflicted, superficial cuts going up and down his right arm. Which of the following actions the nurse take first ? a. Implement the client's behavioral modification plan. b. Document the size and location of the cuts c. Inspect the cuts for debris d. Administer a tetanus antitoxin

c. Inspect the cuts for debris

A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 mL

A nurse is preparing to administer benztropine 2 mg IM every 12 hr to a client who is experiencing an extrapyramidal reaction. Available is benztropine 1 mg/mL for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 mL

A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take? a. Move the client to a private area so the conversation will not be disturbed b. Use clarification to determine what the client is feeling c. Speak to the client using an authoritative voice d.Maintain constant eye contact with the client

b. Use clarification to determine what the client is feeling

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse Is appropriate? a. "This is where you live now." b. "This is a safer place for you to live." c. "Tell me what you like to cook for dinner." d. "Your family said there is no one to care for you at home."

c. "Tell me what you like to cook for dinner."

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process? a. "The doctor has been so good to me. I know he has tried everything he can. It is just my time." b. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!' c. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." d. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.

c. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

A nurse in an emergency department is caring for an adolescent client it who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take? a. Discuss self-defense techniques with the client b. Inform the client photographs of injuries are required for a police report. c. Ask the client to describe the situation. d. Give the client a bed bath prior to physical examination

c. Ask the client to describe the situation.

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? a. "His favorite teacher committed suicide a few weeks ago." b. "He has slept 9 hours each night for the past 2 years." c. "He is very religious and attends services twice a week. d. "He spends much of his time with his two school friends."

a. "His favorite teacher committed suicide a few weeks ago."

A nurse Is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific Individual. Which of the following statements by the newly licensed nurse indicates understanding? a. "I need to make sure that the potential victim is warned." b. "I need to keep the information confidential due to the client's right to privacy. c. "I can only discuss the client's threats with a court order. d. "I should verbally report this information to the psychiatrist."

a. "I need to make sure that the potential victim is warned."

A nurse Is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? a. Alcohol b. Caffeine c. Cocaine d. Inhalants

a. Alcohol

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply) a. Diagnosis of schizophrenia b. Age greater than 55 c. Bachelor's degree d. Male gender e. Recent marriage

a. Diagnosis of schizophrenia b. Age greater than 55 d. Male gender

A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving: a. Leaves the child's room exactly as it was before the loss b. Volunteers at a local children's hospital c. Talks about the child in the past tense d. Visits the child's grave every week after worship services

a. Leaves the child's room exactly as it was before the loss

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate? a. Offer to make arrangements for the Sacrament of the Sick b. Prepare to stay with the client's body after death until family arrives. c. Arrange for a member of the clients faith to bathe the body after death. d. Post a sign on the clients door stating, "No Talking*

a. Offer to make arrangements for the Sacrament of the Sick

A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? a. Situational b. Maturational c. Adventitious d. Developmental

a. Situational

A nurse Is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply). a. Substance use disorder b. Age greater than 45 years old c. Female gender d. Currently married e. Schizophrenia

a. Substance use disorder b. Age greater than 45 years old e. Schizophrenia

A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply.) a. Suicide risk b. Socioeconomic status c. Coping patterns d. Support systems e. Alcohol use

a. Suicide risk c. Coping patterns d. Support systems e. Alcohol use

A nurse Is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identity as placing the client at risk for self-harm behaviors ? a. The client has borderline personality disorder b. The client has a parent who has dependent personality disorder c. The client has a history of bulimia nervosa. d. The client recently received a promotion at work

a. The client has borderline personality disorder

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? a. Provide professional counseling for staff members b. Change policies for staff observation of clients who are suicidal. c. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. d. Give the family an opportunity to talk about their feelings

c. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response? a. "Do you really think your family would be better off without you?" b. "Are you thinking of harming yourself?" c. "Tell me what is happening right now." d. "When did you first start feeling this way?"

b. "Are you thinking of harming yourself?"

A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make? a. "We will call your family in time for them to get here b. "I wonder if you are fearful of dying alone." c. "I will make sure a staff member is in your room at all times. d. "I will tell your family of your concern so that they can be here.

b. "I wonder if you are fearful of dying alone."

A nurse is observing a licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse? a. "Tell me about the concerns that you have regarding your relationship." b. "You should try to see your partner's point of view before your own." c. "We could develop a plan for how to talk about this with your partner." d. "Relationship difficulties are stressful and require effort to resolve."

b. "You should try to see your partner's point of view before your own."

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? a. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight b. A client who has terminal cancer and needs assistance with pain management c. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work d. A client who has dementia and needs help with activities of daily living

b. A client who has terminal cancer and needs assistance with pain management

A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt? a. A client whose family visits him weekly from out of town. b. A client who usually acts impulsively. c. A pregnant female client who is at 6 months gestation d. A client who attends religious services at the mental health facility

b. A client who usually acts impulsively.

A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident? a. Psychologist b. Close friend c. Social worker d. Chaplain

b. Close friend

A nurse In an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect? a. Nystagmus b. Dilated pupils c. Hypersomnia d. Depression

b. Dilated pupils

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first? a. Ask the client for permission to take photographs. b. Document the client's verbatim statements c. Provide community sexual assault support contacts d. Determine any physical signs of injury.

b. Document the client's verbatim statements

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority ? a. Helping the client identify positive personality traits b. Providing for adequate hydration and rest c. Confronting the use of denial and other defense mechanisms d. Educating the client about the consequences of alcohol misuse

b. Providing for adequate hydration and rest

A public health nurse assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? a. Document the bruises in the client's chart b. Report the findings to a supervisor c. Provide the client with a crisis hotline number d. Discuss respite care with the client's family

b. Report the findings to a supervisor

A nurse Is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Acute pancreatitis b. Slowed breathing c. Nasal septum perforation d. Permanent short-term memory loss

b. Slowed breathing

A nurse is caring for client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? a. The client joined a bowling league 2 months ago b. The client has kept his partner's closet untouched since her death. c. The client exercises at a local health facility 3 days each week d. The client meets his daughter for dinner every week

b. The client has kept his partner's closet untouched since her death.

A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? a. The client is 48 years old. b. The client's husband died seven months ago c. The client has lost 30 lb d. The client is having difficulty sleeping.

b. The client's husband died seven months ago

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make ? a. " I can arrange for a female assistive personnel to do your personal hygiene care." b. "The nurse assigned to care for you is very capable and cares for other women in this situation." c. "Your doctor is a man, so it seems like this should not be a problem." d. "I can review the assignments and arrange for a female nurse to care for you."

d. "I can review the assignments and arrange for a female nurse to care for you."

A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? a. "Of course people care. Your family comes to visit every day." b. "Why do you feel that way?" c. "Tell me who you think doesn't care about you." d. "I care about you, and I am concerned that you feel so sad."

d. "I care about you, and I am concerned that you feel so sad."

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? a. "I have heard that abusers try to keep their partner isolated from others. b. "I know that abusers lack social supports and social skills." c. "I know that men who are abusers gain power through intimidation. d. "I have heard that abusers think of themselves as important and have high self esteem."

d. "I have heard that abusers think of themselves as important and have high self esteem."

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse? a. "Evidence must exist prior to reporting. b. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." c. "I don't want to defame someone if the report is false" d. "If suspicion of abuse exists then reporting is mandatory."

d. "If suspicion of abuse exists then reporting is mandatory."

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? a. " Perhaps you should discuss this with your physician" b. "Of course you aren't going to die, at least not in the immediate future." c. "I recommend you exercise daily and avoid smoking to decrease war risk." d. "Tell me more about these fears of dying from a heart attack."

d. "Tell me more about these fears of dying from a heart attack."

A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make? a. "Do not worry about that. Your wife will be fine.* b. "I think you should calm down a little before you see your partner." c. "Why do you think the crash is your fault?* d. "Tell me more about your feelings about what happened to your partner."

d. "Tell me more about your feelings about what happened to your partner."

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate? a. "Tell me why you feel hopeless." b. "I am sure these feelings will pass once you go home." c. "If I were you, I would ask for a referral to hospice care." d. "Tell me what you understand about your Illness."

d. "Tell me what you understand about your Illness."

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? a. "You have a great deal to live for." b. "It's not unusual for depressed people to feel that way." c. "Why do you feel you are worthless?" d. "You've been feeling that your life has no meaning."

d. "You've been feeling that your life has no meaning."

A nurse in the emergency department is planning care for a client who is admitted for an overdose of phencyclidine (PCP). Which of the following actions should the nurse plan to take? a. Administer warmed IV fluids to counteract hypothermia. b. Reverse the toxicity with naloxone c. Verbally attempt to calm the client. d. Administer ammonium chloride.

d. Administer ammonium chloride.

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identity as the priority? a. Lock the doors to the unit and secure windows so the cannot be opened. b. Provide the client with plastic eating utensils for meals c. Remove any objects from the client's environment that could be used for self-harm. d. Assign a staff member to stay with the client at all times

d. Assign a staff member to stay with the client at all times

A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication? a. Invite a family member to be present for the nursing history b. Provide basic wound care for obvious physical injuries. c. Probe the client to offer a factual account of the abuse. d. Be direct and honest when speaking with the client.

d. Be direct and honest when speaking with the client.

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? a. Prior physical health followed by the need for two surgeries within the last three months. b. Obsession over a fictitious defect in physical appearance. c. Sudden unexplained loss of peripheral sensation. d. Constant worry about the undiagnosed presence of an illness

d. Constant worry about the undiagnosed presence of an illness

A nurse Is assessing a client who has post-traumatic stress disorder (PTSD) following a sexual assault. Which of following is an expected finding? a. Sleeping 12 hr or more each day b. Increasing sense of attachment to others c. Constant need to talk about the event d. Increasing feelings of anger

d. Increasing feelings of anger

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention? a. Providing support for family and friends following a suicide b. Identifying individuals who are at higher risk for attempting suicide c. Recognizing the warning signs of suicide d. Performing life-saving measures following a suicide attempt

d. Performing life-saving measures following a suicide attempt

A nurse Is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent? a. Telling his parents that he doesn't want to talk about the suicide attempt. b. Stating that he wants to be with his peers more than with is parents c. Preferring to eat his meals while watching tv d. Planning to give his CD collection to his girlfriend.

d. Planning to give his CD collection to his girlfriend.

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first? a. Call for assistance to place the client in restraints. b. Escort the client to an unlocked seclusion room c. Offer the client a PRN anti-anxiety medication d. Speak to the client calmly, giving simple directions

d. Speak to the client calmly, giving simple directions

A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit? a. The client's vital signs are within the expected re b. The client requests to use the bathroom c. The client eats all of the food provided for each of her meals. d. The client follows directions

d. The client follows directions