340 weeks 2-5

The nurse is assessing a client who​ states, "My family often says that I am​ clingy, that I hate being separated from​ them, and that I go to great lengths to be accepted by them." Based on the client​'s statement during the​ assessment, with which personality disorder does the nurse anticipate this client will be diagnosed by the healthcare​ provider? -Antisocial -Dependent -Paranoid -Avoidant

-Dependent

A nurse treating a client for anorexia nervosa​ (AN) is concerned that the primary disorder has caused other health issues. Which test would the nurse consider for the​ client? -Thematic apperception test -Personality diagnostic questionnaire -Head CT -Electrolyte study

-Electrolyte study

The nurse suspects that the client she is caring for is suffering from Prader-Willi syndrome. During the​ assessment, which specific signs or symptoms would the nurse look​ for? Select all that apply. -Incessant desire to eat -Poor muscle tone -Consumption of nonfood items -Regurgitation of food -Mental retardation

-Incessant desire to eat -Poor muscle tone -Mental retardation

Which psychosocial nursing diagnosis is appropriate for a client with an eating​ disorder? Select all that apply. -Increased risk of anxiety -Alterations in body image -Potential for injury -Decreased​ self-esteem -Impaired nutrition

-Increased risk of anxiety -Alterations in body image -Decreased​ self-esteem

After a lecture by a health department​ nurse, some members of the audience came up to congratulate the nurse on an effective presentation. Which statements by the audience members would the nurse want to​ correct? Select all that apply. "Eighty percent of domestic violence victims are women." "Violence challenges coping efforts." "Elder abuse happens to people over 55 years old." "Domestic violence rates are increasing." "Violence is not preventable."

"Elder abuse happens to people over 55 years old." "Domestic violence rates are increasing." "Violence is not preventable."

The nurse is providing education to a client and family regarding complementary therapies that may be useful in the treatment for Alzheimer disease​ (AD). Which response by the family indicates the need for further​ education? "Selenium is a supplement that is known to support brain function." "Zinc is a supplement known to support brain function." "Huperzine A is an antioxidant that supports brain function." "Coenzyme Q10 naturally occurs in the body and I can take a supplement to support brain function."

"Huperzine A is an antioxidant that supports brain function."

The nurse is preparing to discharge a client who was raped from the emergency department. Which statement indicates a need for additional education before​ discharge? "I live alone and will get my locks changed before I return." "I have an appointment to get my stitches removed in 1 week." "I don​'t need to go to the counselor. I feel fine." "I will stay with my sister for a few days."

"I don​'t need to go to the counselor. I feel fine."

The nurse is caring for an older adult client who is being visited by her daughter who lives several hundred miles away. The daughter asks the nurse which cognitive alterations she should expect as her mother grows older. Which alterations will the nurse include in the response to the client​'s ​daughter? Select all that apply. A decrease in multitasking abilities A decrease in information processing speed Difficulty with receptive language A decline in mental flexibility A decrease in​ long-term memory processing

A decrease in multitasking abilities A decrease in information processing speed A decline in mental flexibility A decrease in​ long-term memory processing

A nurse is checking the patency of the IV in a client who has suffered a major chest trauma. Since the vital signs are showing evidence of​ shock, the nurse expects the physician to order medication to treat that condition immediately. For which kind of medication should the nurse expect a stat​ order? A vasopressor like epinephrine An antibiotic like amoxicillin A mineral replacement like potassium An opioid like morphine

A vasopressor like epinephrine

Although you already know that Joey is a victim of child abuse and​ neglect, it is important for you to assess him for several factors that will give you a​ well-rounded perspective of his health or health risks. What kinds of factors should you consider in your assessment that can help you identify appropriate treatment​ interventions? Behavioral​ factors, such as whether or not Joey​ smokes, uses​ drugs, or drinks Sociocultural​ factors, such as​ Joey's ethnicity, religious​ influences, and socialization skills Biophysical​ factors, such as​ Joey's age, physical​ status, and physical evidence of abuse A combination of​ biophysical, psychological,​ sociocultural, behavioral, and health system factors

A combination of​ biophysical, psychological,​ sociocultural, behavioral, and health system factors

A nurse is looking at the professional literature about children with similar risks of environmental exposure to violence. Which outcomes would the nurse read​ about? Select all that apply. Depression Lethargy Violence Hypertension Nonproblematic behaviors

Depression Violence Nonproblematic behaviors

A nurse has been experiencing horizontal violence on the unit for several months. The nurse manager did not realize what was occurring until he noticed which signs and symptoms in the​ nurse? ​(Select all that​ apply.) Depression Gossiping ​Work-related injuries Isolation Aggressive behavior

Depression ​Work-related injuries Isolation

The nurse is providing care to​ Andy, a​ school-age child brought to the pediatric practice for an examination.​ Andy's mother,​ Noel, tells the nurse that she suspects that Andy has been subjected to sexual abuse by his babysitter. Which approach is most appropriate for the nurse to take when providing care for​ Andy? Ask​ Andy's mother to leave the room to conduct a thorough examination Develop a trusting relationship with Andy by doing exactly what is promised Tell Andy that the babysitter will be made to pay for what he or she did Call the police to report the crime committed against Andy

Develop a trusting relationship with Andy by doing exactly what is promised

After gaining permission to contact Mr. Mercers​ mother, with whom he says he​ lives, you call her. His mother reports that he has been taking olanzapine​ (Zyprexa) to help him manage his​ schizophrenia, but he has been experiencing some side effects. For which adverse effect of olanzapine will you assess Mr.​ Mercer? Flat affect Weight loss Poverty of speech Abdominal pain

Abdominal pain

A client becomes angry with the nurse when breakfast does not arrive on time. Instead of explaining that breakfast is late due to a grease fire in the​ kitchen, the nurse has a nearby diner deliver the client​'s ​breakfast, which the nurse brings to the client​'s room. This action reflects which response to​ conflict? Avoidance Competition Collaborationvvvv Accommodation

Accommodation

Which medication is used to treat clients with​ dementia? Antiemetics ​Beta-blockers Acetylcholine precursors Proton pump inhibitors

Acetylcholine precursors

A nurse manager holds a monthly staffing meeting about understanding and recognizing conflict. Which strategies to prevent or reduce conflict on the unit are appropriate for the nurse manager to​ include? ​(Select all that​ apply.) Acknowledging each other​'s accomplishments Treating each other with respect Addressing issues as they arise Calling in sick during conflict Ignoring each other when angry

Acknowledging each other​'s accomplishments Addressing issues as they arise Treating each other with respect

​Angie, an​ 18-year-old victim of a rape that occurred a month​ ago, has come into the emergency department. Angie is crying and says she has thought about killing herself. Angie states that she has been feeling​ depressed, has been​ nauseated, and has frequent headaches. Which phase of rape trauma syndrome​ (RTS) is she​ experiencing? Acute Anticipatory Reorganization Reconstitution

Acute

The nurse is caring for a client who experienced a blunt force trauma to the abdomen. The client​'s vital signs are​ stable, but the client is complaining of significant pain. Which nursing intervention is the priority for this​ client? Administer analgesic​ medication, per order Palpate the abdomen Monitor stool for blood Assess blood pressure

Administer analgesic​ medication, per order

Which individual is at highest risk for committing assault and​ homicide? Person who witnessed family violence ​Middle-age female Adolescent male Nurse

Adolescent male

An older woman who has been physically and financially abused by her son tells the​ nurse, "I am not pressing charges against my son because I am afraid that he will put me out on the street and I will have no place to​ go." Which response should the nurse include in her interventions for this​ client? Instruct the client not to worry about her son because she is in the​ hospital, so he will not do it again. Support the client​'s wishes to not press charges due to fear. Assess the client​'s safety and help her develop a safety plan. Encourage the client to move out of her son​'s home to avoid future encounters with him.

Assess the client​'s safety and help her develop a safety plan.

During what phase of the nursing process does the nurse collect and document​ ABCDE? Implementation Assessment Diagnosis Planning

Assessment

The telephone advice nurse is fielding a complex question about possible intimate partner abuse. From the description that the caller is​ giving, it seems likely. What is the first priority of the advice​ nurse? Giving information about helpful services Emphasizing that the caller is not to blame for the abuse Exploring the need for resources Assuring safety from the partner​'s abuse

Assuring safety from the partner​'s abuse

Which symptom of schizophrenia is relieved by transcranial magnetic​stimulation? Auditory hallucinations Tardive dyskinesia Visual hallucinations Depression

Auditory hallucinations

The nurses on the unit are giving a presentation on avoiding and managing conflict to their peers in the hospital. The nurses teach that all healthcare professionals should follow which guidelines when conflict​ arises? ​(Select all that​ apply.) Avoid​ emotion-based responses Use critical pathways Focus on exacerbating problems Recognize unsafe behaviors Actively listen

Avoid​ emotion-based responses Actively listen

Jennifer Zimmerman is a​ 25-year-old woman diagnosed with schizophrenia. She dropped out of college during her first psychotic episode a few years ago and now lives with her parents. The nurse is a part of her treatment​ team, which includes her healthcare​ provider, a​ counselor, and her parents. Jennifer has been in regular group therapy and is responding well to her medications. What is the most important goal her treatment team should be working​ toward? Getting her into​ one-on-one therapy Finding her a​ permanent, stable living situation and a job Making sure she follows appropriate​ self-care measures Adjusting her medications

Finding her a​ permanent, stable living situation and a job

Sheila is a​ 32-year-old client who exhibits symptoms of provocative​ behavior, exhibits use of physical appearance to draw attention to​ herself, and is very theatrical. She has been diagnosed with histrionic personality disorder. Which collaborative therapy is not appropriate for Shelia based on her​ diagnosis? ​-Schema-focused therapy -Dialectical behavioral therapy ​-Cognitive-behavioral therapy -Group therapy

Group therapy

A client diagnosed with schizophrenia is regularly experiencing command​ hallucinations, evidence of loose​ associations, and perseverative speech. When creating a plan of care for the​ client, why should the nurse not recommend group​ therapy? Group therapy is useful only for depression. Group therapy can be provided only in an inpatient setting. Group therapy can be too stimulating for some clients with schizophrenia. Group therapy is never used in schizophrenia.

Group therapy can be too stimulating for some clients with schizophrenia.

A nurse in a​ long-term care facility is providing care for a client who is receiving memantine for Alzheimer disease​ (AD). Which adverse reaction to the medication would the nurse report to the healthcare​ provider? Hypotension Guaiac positive stool Weight gain Tachycardia

Guaiac positive stool

Diagnostic tests are performed when a victim of rape comes to the emergency department or crisis center. Which test is performed initially and then again at​ 3, 6, and 12 months after the​ attack? HIV infection Chlamydia Ultrasound Pregnancy

HIV infection

You are preparing Mr. Mercer for discharge. You are teaching him about his new medications and their side​ effects, as well as helping him develop a relapse prevention plan. Which teaching point is most important for Mr. Mercer to understand to prevent an exacerbation of his​ schizophrenia? He must taper his medication down to zero and not stop suddenly. He needs to find a job or some form of community work to engage his mind. He must continue to take his medications even when he starts to feel better. He needs to find a way to stay active and productive each day.

He must continue to take his medications even when he starts to feel better.

You are assessing​ Marcus, a child whose teacher suspects he is the victim of abuse or neglect. Your physical assessment of Marcus reveals no unexplained or untreated​ injuries, and Marcus does not appear to be malnourished or dehydrated. Which clinical manifestation would indicate to you that Marcus might be the victim of abuse or​ neglect? He tells you he​ doesn't like going to the doctor. He repeatedly bites his nails. He has a bandage over a scrape on his knee. He is friendly with strangers.

He repeatedly bites his nails.

Which behavior should a nurse least expect while assessing a client with a suspected eating​ disorder? -Secrecy -Deceit -Denial -Healthy body image

Healthy body image

Mrs. Weddles daughter has expressed concern with Mrs. Weddle experiencing sundowning. What are appropriate nursing interventions to minimize​ sundowning? Select all that apply. Turn on Mrs. Weddles favorite television show during the evening hours. Assist the Mrs. Weddle with her bath before bedtime even if she refuses it. Encourage Mrs. Weddle and her daughter or a friend to go for walks in the neighborhood each day. Keep the house well lit during the day and darker at night. Limit​ caffeine, especially toward the evening hours.

Encourage Mrs. Weddle and her daughter or a friend to go for walks in the neighborhood each day. Keep the house well lit during the day and darker at night. Limit​ caffeine, especially toward the evening hours.

A unit nurse asks the nursing assistant to take vital signs. The nursing assistant immediately becomes​ defensive, complaining that​ "Nurses never take care of their own​ patients!" Which action is priority in resolving this​ conflict? Decrease personal stress levels before discussing the issue. Explain the duties and responsibilities of a nursing assistant. Define the roles of the nursing assistant and other team members. Acknowledge the nursing​ assistant's accomplishments and ask for the vital signs again.

Decrease personal stress levels before discussing the issue.

As you assess Mrs.​ Weddle, she becomes tearful and​ says, I dont know why everyone wants to pick on me. A few moments​ later, she becomes agitated and​ hateful, yelling, Just get me out of this​ place! Which diagnostic tests do you suspect the health care provider will complete to confirm a diagnosis of Alzheimer disease for Mrs.​ Weddle? Select all that apply. Playing a memory card game with the client CAT scan MRI scan ​Alzheimer-focused assessment noting signs and symptoms of Alzheimer disease Brain tissue pathology

CAT scan MRI scan ​Alzheimer-focused assessment noting signs and symptoms of Alzheimer disease

The nurse is assisting in the initial physical examination for a victim of rape. The nurse performs which action to assist with collection of evidence during this​ examination? Select all that apply. Collecting skin scrapings from fingernails Drawing blood for an electrolyte panel Examining the client​'s ​vagina, anus, and throat Collecting the client​'s clothing Drawing blood for a complete blood count

Collecting skin scrapings from fingernails Examining the client​'s ​vagina, anus, and throat Collecting the client​'s clothing

A physician asks the nurse about providing an advanced cardiac life support​ (ACLS) class for the new medical residents and nurses hired last week. A second physician does not believe a nurse to be qualified to teach this course. What type of relationship is the first physician exhibiting to decrease conflict among healthcare​ providers? Avoidant Collegial Accommodating Collaborative

Collegial

A nurse is preparing a community teaching presentation on prevention of abuse. Which levels of prevention should be included in the nurse​'s ​presentation? Select all that apply. Community Individual Societal Historical Parental

Community Individual Societal Parental

Mr. Mercer will be going to live with his mother upon discharge. Preparing Mr. Mercer to return to the community includes referral to programs that can help him manage his schizophrenia. To which type of program do you plan to refer Mr.​ Mercer? Community day treatment programs Group homes and community living arrangements Home health programs Vocational counseling

Community day treatment programs

Which elements constitute a safe environment for a client with cognitive​ impairments? Select all that apply. Prevention of wandering Limiting phone access Minimization of fire and fall hazards Restricting access to medications Providing such environmental clues as calendars

Prevention of wandering Minimization of fire and fall hazards Restricting access to medications Providing such environmental clues as calendars

The nurse is providing counseling to the incarcerated perpetrator of rape. Which finding in the​ client's history are known risk factors for those who commit the act of​ rape? Select all that apply. Raised in an urban environment Previously abused as a child Age Antisocial behaviors Alcohol or drugs

Previously abused as a child Antisocial behaviors Alcohol or drugs

Which are appropriate assessments for the nurse to collect and document for a client who is the victim of assault or an attempted​ homicide? Select all that apply. Prioritization of injuries Client and nurse safety MRI ABCDE SAM

Prioritization of injuries Client and nurse safety ABCDE

The nurse is conducting an assessment for a client diagnosed with delirium. Which risk factor found in the client​'s health history may have caused the current​ diagnosis? History of hypertension Recent heroin use Diet high in folic acid History of anorexia nervosa

Recent heroin use

The community health nurse would like to implement community interventions to decrease the number of assaults and homicides that have occurred in the community over the past year. Which actions by the nurse are appropriate to meet this​ goal? Select all that apply. Identify​ at-risk youth. Offer school safety and anger management programs. Teach children when bullying is appropriate. Involve community professionals from​ schools, health​ departments, law​ enforcement, social services. Hold programs at neutral locations outside the community.

Identify​ at-risk youth. Offer school safety and anger management programs. Involve community professionals from​ schools, health​ departments, law​ enforcement, social services. Hold programs at neutral locations outside the community.

The health care provider ordered donepezil hydrochloride​ (Aricept) for Mrs. Weddle. You complete your medication teaching with Mrs. Weddle and her daughter. Which statement by her daughter indicates the need for further​ teaching? Im so happy this medication will help cure her Alzheimer disease and she can function normally every day. I will have her take the oral dissolving tablet with a full glass of water one time per day. This medication can be used in late stage Alzheimer disease. I will make sure she monitors her pulse and takes it at bedtime.

Im so happy this medication will help cure her Alzheimer disease and she can function normally every day.

A nurse is interviewing a client diagnosed with schizophrenia. The client repeats the last two words of the nurse​'s question several times before he responds. Based on this​ interview, which is an appropriate problem to address when caring for this​ client? Social isolation Potential for injury Impaired memory Impaired verbal communication

Impaired verbal communication

Which are important elements of client and family education that the nurse should provide for individuals with cognitive​ disabilities? Select all that apply. Important elements of client care Referral for residential care Explanation of the diagnosis Stories about neighbors with the same condition Expected course of the condition

Important elements of client care Explanation of the diagnosis Expected course of the condition

Mrs. Martinez​ asks, "What are the warning signs that someone is a child​ abuser? Are there​any?" You think about this question and come up with some factors that can potentially describe someone who is at risk for abusing others. What are some of the factors that you mention to Mrs.​ Martinez? Select all that apply. Someone who does not have any children Recent increased​ stressors, such as​ pregnancy, job​ loss, or health condition Being unattractive Alcohol​ and/or drug use and abuse Having feelings of isolation

Recent increased​ stressors, such as​ pregnancy, job​ loss, or health condition Alcohol​ and/or drug use and abuse Having feelings of isolation

The nurse is providing care for a client with alcoholism who was admitted to the substance abuse unit. The client is the same age as the​ nurse's father, who recently passed away. The nurse asks to be taken off the​ client's care team. What step has this nurse taken to manage possible conflict in this​ situation? Listening to her​ "inner" voice Refusing to take care of a stressful client Knowing what clients can​ "push" her buttons Recognizing a source of stress in the workplace

Recognizing a source of stress in the workplace

​Jamie, an​ RN, has been experiencing job stress since starting a new position in the ICU. What is the first strategy that Jamie will use to decrease or manage stress levels in the workplace to reduce the likelihood of​ conflict? Encouraging others Recognizing her own stress Avoiding destructive criticism Listening to others

Recognizing her own stress

The nurse on the pediatric unit is caring for a​ 3-year-old child who has​ dime-size burns on her legs and bruises in various stages of healing on her abdomen and back. Which is an appropriate nonpharmacologic treatment for this​ child? Give acetaminophen as ordered by the physician. Treat the burns with silvadene ointment. Refer the child for play therapy. Assess the child​'s back and abdomen for any changes.

Refer the child for play therapy.

A​ 39-year-old client who is a pastor indicates that he regularly hears the voice of God telling him to repent and that this voice disturbs him. How should the nurse respond to this​ client? Instruct the client to ignore the voice. Tell the client that he is having an auditory hallucination. Refer the client for further work up of auditory hallucination Inform the client he is lucky to have a direct connection to God.

Refer the client for further work up of auditory hallucination

Which is an example of a collaborative intervention by a nurse working with a client who has experienced elder​ abuse? Completing mandatory reports to authorities Exploring options for help Sharing information about services Referring the client to a social worker case manager

Referring the client to a social worker case manager

The health care provider diagnosed Mrs. Weddle with Alzheimer disease. Her daughter is very concerned about the behaviors that Mrs. Weddle could exhibit as the disease progresses. Which behaviors are commonly exhibited by clients with Alzheimer​ disease? Select all that apply.​ Refusing to bathe Difficulty understanding language and speech Accusing a family member of stealing possessions Outbursts of combative behavior Organizing the bathroom closet

Refusing to bathe Difficulty understanding language and speech Accusing a family member of stealing possessions Outbursts of combative behavior

The nurse who is caring for a client who was a victim of intimate partner violence​ (IPV) is aware that recovery from this type of relationship can be a long and difficult process. Which should the nurse identify as the victim​'s main goal in reconstructing her​ life? Regaining a sense of empowerment and safety Resolving grief over any losses Getting through the shock and confusion of the act Getting back into work and home routines

Regaining a sense of empowerment and safety

Which are expected outcomes for clients with​ delirium? Select all that apply. Remain free of injury. Verbalize feelings of being able to cope with the disease. Prepare advanced future planning for progressive disease stages. Return to an optimal level of​ functioning, if possible. Maintain adequate nutrition.

Remain free of injury. Return to an optimal level of​ functioning, if possible. Maintain adequate nutrition.

The nurse is planning care for a client who is diagnosed with delirium. Which cognitive intervention is appropriate for this​ client? Monitoring intravenous fluids Reorienting to time and place Administering oxygen Providing nutrition

Reorienting to time and place

The nurse is providing care to a client who is the victim of a stabbing. Which initial treatment is most appropriate for this​ client? Pain​ management, surgery to remove bullet​ and/or repair​ damage, and replacement of fluids Replace blood​ loss, treat for​ shock, and repair the damage Immobilization of the area to prevent further movement of the bone and allow for healing Diagnostic tests to find the source of​ bleeding, surgery to stop the bleeding and repair injury

Replace blood​ loss, treat for​ shock, and repair the damage

An alert and oriented older adult client is receiving home care services following a cerebrovascular accident that has left her with​ right-sided hemiparesis. She lives with her daughter and​ son-in-law. The nurse suspects that the client is being neglected when she observes that the client​'s hair and clothes are dirty and the client smells of urine. Which nonpharmacologic treatment would be a priority for this​ client? Report the neglect to the appropriate agency Wait until enough trust has been developed to enable the client to approach the nurse first Interview the​ son-in-law to gain his perspective on the situation Confront the daughter with the suspicions

Report the neglect to the appropriate agency

Which nonpharmacologic treatment is appropriate in an abuse situation involving an older​ adult? Report the situation to the proper​ agency, and provide support for the victim. Protect the client​'s privacy by not documenting the abuse. Provide counseling to the person committing the abuse. Provide counseling for the victim.

Report the situation to the proper​ agency, and provide support for the victim.

Which are appropriate nursing interventions for child abuse and​ neglect Select all that apply. Reporting the abuse Encouraging the child to confront the abuser Promoting a trusting relationship Developing rapport Initiating a complete physical assessment

Reporting the abuse Promoting a trusting relationship Developing rapport Initiating a complete physical assessment

Which are forms of nonpharmacologic treatment of elder abuse and​ neglect? Select all that apply. Referral to a homeless shelter Respite care for caregiver Elder abuse reported to appropriate agency Safe living environment Adult day care

Respite care for caregiver Elder abuse reported to appropriate agency Safe living environment Adult day care

Which expected outcome is not appropriate for a client diagnosed with Alzheimer disease​ (AD)? Maintain an adequate balance of activity and rest. Maintain adequate nutrition. Restores previous level of functioning. Maintain an adequate fluid and electrolyte balance.

Restores previous level of functioning.

Which medication would the nurse administer with food for a client who is diagnosed with Alzheimer disease​ (AD)? Donepezil hydrochloride​ (Aricept) Tacrine hydrochloride​ (Cognex) Memantine​ (Namenda) Rivastigmine tartrate​ (Exelon)

Rivastigmine tartrate​ (Exelon)

Ms.​ Burgos, age​ 35, is admitted to the emergency department with a gunshot wound. She reports having been shot by her​ husband, who is still at large. The​ client's vital signs are stable. Which assessment is now the priority for this​ client? Prioritization of client injuries Preparation for colonoscopy Safety of client ABCDE assessment

Safety of client

The nurse knows that role expectations and boundary issues are a primary source of conflict within health care. What are some issues within this primary source that cause​ conflict? ​Select all that​ apply. Effective communication Inaccurate information Lack of understanding Resistance to change Cooperation

Inaccurate information Lack of understanding Resistance to change

​Julie, a novice​ nurse, is explaining the plan of care to Mr.​ Baker, a client who is being seen by a primary care physician. The client​ states, "I​ don't exactly understand why I am​ here." The nurse tells the client that she will get someone to explain further and calls the preceptor to the consultation room to help with clarification. The preceptor states she cannot help right now because Julie needs to​ "stand on her own two​ feet." Julie and the preceptor have a heated discussion with the nurse manager regarding this incident. Which common cause of workplace conflict is depicted in this​ scenario? Miscommunication Ineffective leadership Ambiguous role expectations Mistrust

Ineffective leadership

Which are potential precipitating factors associated with​ delirium? Select all that apply. Excessive sleep Infection Moderate alcohol use History of falls Fracture or trauma

Infection History of falls Fracture or trauma

A nurse is reading a newspaper report about a​ 60% decrease in domestic violence over the past few years. What kind of factor does this statistic​ represent? Predisposing factor Protective factor Influencing factor Precipitating factor

Influencing factor

Which are appropriate nursing interventions for intimate partner​ violence? Select all that apply. Initiating a thorough physical and emotional assessment Offering resources and assistance Mediating discussion between the victim and the abuser Giving the client your opinion of his or her intimate partner Documenting the description and location of any injuries

Initiating a thorough physical and emotional assessment Offering resources and assistance Documenting the description and location of any injuries

The nurse is caring for a​ school-age client who is prescribed methyphenidate​ (Ritalin) for attention deficit hyperactivity disorder​ (ADHD). Which adverse effects will the nurse include in the medication​ teaching? Select all that apply. Hypertension Decreased appetite Increased heart rate Hypothyroidism Insomnia

Insomnia Increased heart rate Decreased appetite Hypertension

A student nurse is writing a research paper on developmental disabilities for a psychology class. Which developmental disability will the student include that is the most​ prevalent? Learning disability Psychosis Dementia Intellectual disability

Intellectual disability

Which factors increase the risk for interpersonal violence or​ abuse? Select all that apply. Intellectual disability Presence of firearms in the home Being an older adult High socioeconomic status Being a young child

Intellectual disability Presence of firearms in the home Being an older adult Being a young child

What is the definition of physical​ neglect? Intentionally causing physical harm to another Ignoring​ one's own physical and healthcare needs Intentionally causing psychological harm to another Intentionally ignoring the physical needs of another

Intentionally ignoring the physical needs of another

Two hospitals in a small town have applied for Magnet status. Hospital A has achieved this​ status, while Hospital B is still on their Magnet journey. Hospital B is now offering​ sign-on bonuses to entice BSN prepared staff members to join their team. What type of conflict could occur in this​ situation? Intrapersonal conflict Interorganizational conflict Interpersonal conflict Intergroup conflict

Interorganizational conflict

The nurse in the emergency department is caring for a woman of Asian descent who was brought in by a neighbor. The right side of the client​'s face is​ swollen, bruised, and bleeding. She has multiple bruises on her arms. The client​'s husband arrives and does not let her​ speak; he answers questions for her. The nurse should suspect which type of​ abuse? Financial abuse Intimate partner violence Rape Elder abuse

Intimate partner violence

Dawn, a nurse​ manager, approaches​ Jarrod, an RN who works third shift on their​ unit, and offers him the opportunity to become the charge nurse on first shift. The job comes with an increase in responsibility as well as a pay raise and bonuses. Jarrod​ answers, "I have to discuss this with my wife. Can I have time to think about my​ decision?" What is the best description of the type of conflict Jarrod may be​ experiencing? Interpersonal Interorganizational Intrapersonal Intergroup

Intrapersonal

During the nursing assessment​ interview, which complaints might be associated with physical​ abuse? Select all that apply. Urinary tract infection Irritable bowel syndrome Depression Headache Chronic pelvic pain

Irritable bowel syndrome Depression Headache

A nurse and a family member are having a disagreement in the​ client's room. The conversation is verging on an argument. The nurse manager knows that which items are critical to manage this conflict and prevent further​ escalation? ​ Select all that​ apply. Listening to both sides Expressing empathy and consideration of both parties Siding with the nurse in this conflict Setting limits on acceptable levels of hostility Clearly communicating limits of behavior

Listening to both sides Expressing empathy and consideration of both parties Clearly communicating limits of behavior

Which intervention is appropriate for inclusion in a plan of care for a client with​ schizophrenia? Select all that apply. Maintaining a safe environment. Monitoring for acute pain. Creating a stimulating environment. Providing family education. Avoiding setting limits.

Maintaining a safe environment. Providing family education.

A​ 21-year-old college student is brought to the infirmary by a friend. As he paces back and​ forth, the student says he is hearing voices and is unable to study. Which possible diagnosis must be ruled out before a diagnosis of schizophrenia can be​ made? Select all that apply. Medication reaction Coronary heart disease Depression Brain tumor Bipolar disorder

Medication reaction Depression Brain tumor Bipolar disorder

A client is experiencing continuous auditory hallucinations but is refusing to take the prescribed medications. What potential reason for the client​'s behavior should the nurse​ explore? Availability of group therapy Cause of the hallucinations Medication side effects Recent hospitalization

Medication side effects

Which data are used to diagnose Alzheimer disease​ (AD)? Select all that apply. Mental status examination Borg scale Braden scale Presence of dementia ​SF-36 health survey

Mental status examination Presence of dementia

After speaking with Mrs.​ Pinkard, what is a reasonable conclusion to make regarding her role in​ Joey's abuse? Select all that apply. Mrs. Pinkard was abusive by default because her​ son, Joey's​ dad, was abusive Mrs. Pinkard may be guilty of being neglectful if she witnessed the behaviors occurring in the​ home, but did not take preventative steps to help protect Joey Mrs. Pinkard​ can't possibly be guilty of neglect because the abuse did not occur in her home Mrs. Pinkard is certainly guilty of abuse and neglect Mrs. Pinkard admitted to being abused​ herself, by her own​ son, and was probably not abusive to Joey

Mrs. Pinkard may be guilty of being neglectful if she witnessed the behaviors occurring in the​ home, but did not take preventative steps to help protect Joey Mrs. Pinkard admitted to being abused​ herself, by her own​ son, and was probably not abusive to Joey

Mrs. Weddle asks her​ daughter, What are we waiting on​ here? As you assess Mrs.​ Weddle, you have noticed various warning signs of Alzheimer disease. Which of the following are considered warning signs of Alzheimer​ disease? Select all that apply.​ Mrs. Weddle​ states, Im​ cold, please find me a sweater. Mrs. Weddle is unkempt and smells of body odor. As she waits to see the health care​ provider, Mrs. Weddle becomes agitated and asks her daughter​ sharply, What do we need from​ here? Mrs. Weddle wore mismatched shoes. Mrs. Weddle had a spoon in her purse.

Mrs. Weddle is unkempt and smells of body odor. As she waits to see the health care​ provider, Mrs. Weddle becomes agitated and asks her daughter​ sharply, What do we need from​ here? Mrs. Weddle wore mismatched shoes. Mrs. Weddle had a spoon in her purse.

Joey's father refused to fill his prescriptions for a conduct disorder. Because Joey and Mrs. Pinkard are unable to recall the name of the​ drugs, what kind of action can you take to show your due diligence and help get Joey regulated on his meds​ again? Give Joey a list of prescription drug names and have him select the one that he thinks he used to take. Call​ Joey's dad and ask him nicely on the phone to give him the name of the prescription. Schedule Joey for an appointment with the unit psychiatrist who will determine what types of medications Joey should​ take, if any at all. Contact​ Joey's school nurse and ask if she knows the name of the medications Joey was taking.

Schedule Joey for an appointment with the unit psychiatrist who will determine what types of medications Joey should​ take, if any at all.

What are cognitive structures referred to in Piaget​'s developmental​ theory? Carphologia Schemata Trisomy Echolalia

Schemata

The number of women who report being raped is estimated at 1 in 5. Of this​ number, how many report being raped before reaching 18 years of​ age? Over​ 15% Over​ 40% Less than​ 22% Less than​ 37%

Over​ 40%

Which nursing diagnosis is the most appropriate for the physical injuries that occur as the result of a​ rape? Potential for powerlessness Pain Decreased​ self-esteem Decreased​ self-concept

Pain

Which is a behavioral therapy for individuals who abuse​ children? Select all that apply. Parenting skills classes Substance abuse therapy Assertiveness training Anger management training Play therapy

Parenting skills classes Substance abuse therapy Anger management training

Which strategies are used by older adults to decrease cognitive​ decline? Select all that apply. Participating in activities that use mental skills Watching television Maintaining social networks and supports Using such mnemonic strategies as word​ association, to learn new information Exercising regularly

Participating in activities that use mental skills Maintaining social networks and supports Using such mnemonic strategies as word​ association, to learn new information Exercising regularly

Which disorder is not diagnosed using brain​ imaging? Schizophrenia Brain tumor Fluid buildup Stroke

Schizophrenia

A nurse is completing a health history of a​ 15-year-old client to assess for possible schizophrenic indications. What information should the nurse obtain during this​ assessment? Select all that apply. Paternal age Maternal age Drug and alcohol use Assessment of daily functioning Presence of symptoms

Paternal age Drug and alcohol use Assessment of daily functioning Presence of symptoms

A nurse in the emergency department is bandaging the forearm of​ 26-year-old Marcus Hanson. He was stabbed in the arm more than a week​ ago, and the untreated wound is infected.​ "It was​ self-defense," explains Mr. Hanson. The nurse notices a gang tattoo on Mr.​ Hanson's biceps. What supposition can the nurse make about why Mr. Hanson delayed seeking​ treatment? Forearm wounds are visible and embarrassing. People do not recognize signs of infection. Forearm wounds often heal by themselves. People in gangs or associated with crimes delay seeking medical attention.

People in gangs or associated with crimes delay seeking medical attention.

A student nurse is preparing a presentation regarding those who commit murder. Which​ description, that is particularly characteristic of murderers with antisocial personality​ disorders, will the student nurse include in the​ presentation? Person finds social reactions to the offenses reinforcing. Person commits violent personal crimes to achieve a goal. Person has low rates of committing another murder. Person is a gang member.

Person finds social reactions to the offenses reinforcing.

In addition to the​ clozapine, the psychiatrist prescribes benztropine​ (Cogentin) to treat the extrapyramidal symptoms​(EPS) that Mr. Mercer has been experiencing as the result of​long-term use of a phenothiazine. In his care​ plan, you document that Mr. Mercer must be monitored for which side effects of​ benztropine? Select all that apply. Photophobia Dry mouth Bradycardia Decreased sweating Central nervous system stimulation

Photophobia Dry mouth Decreased sweating Central nervous system stimulation

You are the intake nurse working overnight on the​ children's unit of an inpatient psychiatric hospital. Joseph​ ?Joey? Pinkard, a​ 9-year-old Caucasian​ boy, is brought to the unit by his Child Protective Services​ (CPS) caseworker, Marie​ Plum, and his​grandmother, Mrs. Pinkard. They have come from the emergency department​ (ED), where Joey was seen after his grandmother found him at​ home, hiding from his father Richard. Richard was​ ?passed out​ drunk? after throwing a heavy stack of books at​Joey's feet and pushing his face into the corner of the kitchen counter. Joey now has a bandage across his forehead and a cast on his left foot. He has visible bruises on his right​ arm, scratch marks on his​ face, and appears underweight for his​ age. The assessment begins with Ms. Plum giving you background information on Joey. She tells you that Joey lives with his​ father, Richard, and his​ grandmother, Mrs. Pinkard. The ED and CPS assessments revealed that​ Joey's dad is addicted to alcohol and regularly abuses both Joey and his grandmother. Mrs. Pinkard reports that​ Joey's dad has become more abusive since he lost his job a couple of months ago when he showed up to work under the influence. He has worked some temporary jobs since​ then, but he spends most of that money on beer instead of buying food for the house. Some of Mrs.​Pinkard's friends know about their situation and bring the family dinner from time to​ time, but Joey has become frailer and frailer due to malnourishment. Mrs. Pinkard reports that Joey was recently diagnosed with a conduct​ disorder, but​ Joey's dad will not pay for the medication. Mrs. Pinkard is not able to remember the name of the medications Joey is supposed to take and reports that​ it's been several weeks since Joey has been on his​meds. Upon hearing​ this, the officials and CPS caseworker decided to transfer Joey to the​children's psychiatric unit to get his behavioral health needs met. Ms.​ Plum, the​caseworker, informs you that upon discharge from your​ unit, the plan is to place Joey in foster care to assure his safety. You ask Mrs. Pinkard how long the child abuse and neglect has been occurring. She says that​ Joey's father has been abusive when he drinks for the past couple of years. She says she is not aware of any neglect. She tells you that Joey was never left at the house​ alone, so therefore he​ wasn't neglected. What can you tell Mrs. Pinkard about the definitions of abuse and​ neglect? Select all that apply. Neglect only has to do with children who are not bathed regularly. Physical abuse and neglect are forms of child abuse. Child abuse also includes emotional abuse. Maintaining a filthy or hazardous home constitutes child abuse and neglect. Not providing food for children and not providing prescription medications are forms of neglect.

Physical abuse and neglect are forms of child abuse. Child abuse also includes emotional abuse. Maintaining a filthy or hazardous home constitutes child abuse and neglect. Not providing food for children and not providing prescription medications are forms of neglect.

Which traits are associated with Down​ syndrome? Select all that apply. Large ears Physical disabilities Congenital heart defects Crossed eyes Eventual dementia

Physical disabilities Congenital heart defects Eventual dementia

The nurse is writing a plan of care for a client who is the victim of rape. Which nursing diagnosis does not support the client​'s psychosocial​ needs? Physical pain Powerlessness Impaired coping Decreased​ self-esteem

Physical pain

A nurse on the​ medical-surgical unit has identified safety as a priority problem for a client who is in the late stages of Alzheimer disease​ (AD). The client is awake at night and tends to wander. Which priority interventions would the nurse use in the care of this​ client? Select all that apply. Place nonskid slippers on the client. Place a vest restraint on the client. Keep the client​'s room free of clutter. Keep a nightlight on in the room. Take the client to the bathroom every 2 hours.

Place nonskid slippers on the client. Keep the client​'s room free of clutter. Keep a nightlight on in the room. Take the client to the bathroom every 2 hours.

Which actions are appropriate nonpharmacologic treatments of a neglected or abused​ child? Select all that apply. Play therapy Family therapy for the parents Reporting the abuse or neglect to the appropriate agency Pain medication for the child​'s injuries Providing a safe environment for the child

Play therapy Family therapy for the parents Reporting the abuse or neglect to the appropriate agency Providing a safe environment for the child

Which characteristic psychoanalytic explanation is associated with​ schizophrenia? Impaired interpersonal relationships Poor bonding between infant and mother due to the mother​'s anxiety An inherited gene Excessive stress that is not relieved by using normal coping strategies

Poor bonding between infant and mother due to the mother​'s anxiety

A public health nurse is visiting the home of Hazel​ Harrington, a​ 90-year-old woman with diabetes. Looking out the​ window, the nurse sees​ graffiti, empty beer​ cans, and discarded trash items. Which kind of environmental factor for violence would the nurse become aware​ of? Predisposing factor Protective factor Precipitating factor Reactive factor

Predisposing factor

The nurse educator asks a group of students to name the stages of development identified by Piaget. Which responses indicate understanding of Piaget​'s ​theory? Select all that apply. Preoperational Postoperational Concrete operational Sensorimotor Formal operational

Preoperational Concrete operational Sensorimotor Formal operational

The nurse is providing care to a client who has experienced a gunshot wound. During the​ assessment, the nurse notes that the client​'s blood pressure has significantly dropped and symptoms of shock are occurring. Which nursing intervention is a priority for this​ client? Update the client​'s family on the current condition Prepare intravenous fluid administration Prepare the client for intubation Administer a pain​ medication, per order

Prepare intravenous fluid administration

The nurse is providing care to a client who is diagnosed with delirium. The client​'s family asks what they can expect. Which symptoms of delirium will the nurse include in the response to the​ family? Select all that apply. Sudden loss of both​ long-term and​ short-term memory Might look physically​ unwell; acute onset of irrational and repetitive behaviors Chest pain that radiates to the left arm Fluctuations in the intensity and level of​ consciousness, from drowsy to near unconsciousness Manic behavior and flight ideas

Sudden loss of both​ long-term and​ short-term memory Might look physically​ unwell; acute onset of irrational and repetitive behaviors Fluctuations in the intensity and level of​ consciousness, from drowsy to near unconsciousness

Which contributes to the shorter life expectancy of clients with​ schizophrenia? Select all that apply. Suicide Accidents Coronary heart disease Brain cancer Complications of type 2 diabetes mellitus

Suicide Accidents Coronary heart disease Complications of type 2 diabetes mellitus

Mr. Mercers mother tells you​ that, prior to taking the​ olanzapine, he took chlorpromazine​(Thorazine) for several years. For which adverse effect of chlorpromazine will you monitor Mr.​ Mercer? Shivering Suicidal thoughts Tardive dyskinesia Anxiety and restlessness

Tardive dyskinesia

A public health nurse is the guest speaker at a PTA meeting. The nurse describes how parents​' activities can decrease the risk of violence in their family. Which actions supported by CDC research will the nurse​ include? Select all that apply. Showing interest in the child​'s homework Watching the child​'s sports team play Regularly attending worship services together Achieving financial success Rewarding good report cards

Showing interest in the child​'s homework Watching the child​'s sports team play Regularly attending worship services together Rewarding good report cards

The nurse is providing care to a client who is the victim of rape. Which intervention is appropriate for this​ client? Select all that apply. Taking the history of the incident in the triage area before the physical assessment. Submitting referrals to a social​ worker, counselor, and support groups. Placing the client in a private room for assessment and collection of evidence. Treating the client for sexually transmitted infections. Administering emergency contraceptive medications.

Submitting referrals to a social​ worker, counselor, and support groups. Placing the client in a private room for assessment and collection of evidence. Treating the client for sexually transmitted infections. Administering emergency contraceptive medications.

A nurse educator is preparing a presentation for a group of students regarding Alzheimer disease​ (AD). Which statement regarding the early pathophysiological changes that occur with this disease process indicates appropriate understanding by the students who attended the​ presentation? Deposits of insoluble material accelerate neuron impulses early in the disease. There are deposits of a​ fat-soluble material in the speech areas of the​ brain, caused by poor​ circulation, early in the disease. There are deposits of insoluble material in the memory and cognition areas of the brain early in the disease. The neurons secrete a substance that causes the growth of abnormal neurons.

There are deposits of insoluble material in the memory and cognition areas of the brain early in the disease.

You have completed your teaching on Alzheimer disease. Mrs. Weddles daughter​ states, Im really concerned about Mom wandering at night. What strategies would you suggest to help prevent Mrs. Weddle from​ wandering? All Alzheimer clients wander. There really isnt anything you can do to prevent it. There are many client tracking devices available on the market. You could lock her in her room at night. You can apply wrist restraints at night to keep her in bed.

There are many client tracking devices available on the market.

Which are characteristics of the influencing factors of​ violence? Select all that apply. They follow laws. They define trends. They are not causative. They are not predictive. They identify warning signs.

They define trends. They are not causative. They are not predictive. They identify warning signs.

Which initial client goals and outcomes may be included in the plan of care for a client who is the victim of a gunshot​ wound? Select all that apply. The​ client's airway will remain patent. The client will demonstrate no signs or symptoms of infection. The​ client's pain will be tolerable. The client will receive assisted ventilation as needed. The client will not have hypothermia.

The​ client's airway will remain patent. The​ client's pain will be tolerable. The client will receive assisted ventilation as needed. The client will not have hypothermia.

Mrs. Pinkard informs you that she never knew how to stop​ Joey?s dad from abusing him. She knew that Richard needed help with his​ drinking, and wonders what she could have done to protect Joey from harm. Given what you know about Richard and the​ family?s situation, what types of strategies might have been effective in preventing the​ abuse? Select all that apply. Teaching Richard coping and stress management skills Screening for abuse in the​ home, and addressing the immediate dangers Teaching Joey how to fight back Helping Richard learn conflict management techniques Teaching Joey how to handle the situation when his dad becomes abusive

Teaching Richard coping and stress management skills Screening for abuse in the​ home, and addressing the immediate dangers Helping Richard learn conflict management techniques

Joey looks directly at you and​ asks, "Why would my dad hit​ me? Aren't dads supposed to love their​ kids?" What is a clinically and​ age-appropriate response to​ Joey's question? Tell Joey that many people who are abusive were abused themselves when they were younger. Tell Joey that parents never abuse their​ children, so there must be something clinically wrong with his dad. Tell Joey that only children from certain backgrounds are victims of child abuse. Tell Joey that only strangers are child abusers.

Tell Joey that many people who are abusive were abused themselves when they were younger.

The nurse is assessing the plan of care initiated for a client who is the victim of rape. Which finding indicates that the plan of care should be​ revised? The client has asked for a rape counselor. The client has allowed physical evidence to be collected. The client has agreed to the physical assessment. The client has refused to report the rape or accept help.

The client has refused to report the rape or accept help.

​Maria, a​ 32-year-old client, is being seen at the counseling center and reports insomnia and flashbacks. As the nurse assesses​ Maria, which finding does not demonstrate that she has recovered from sexual​ violence? The client demonstrates effective coping. The client reports a decrease in physical symptoms. The client reports that memories of the rape are frequently the center of her thoughts. The client reports a decrease in negative feelings.

The client reports that memories of the rape are frequently the center of her thoughts.

A​ 24-year-old client is diagnosed with schizoaffective disorder. Although he is participating in an occupational training​ program, his clothing is dirty and​ rumpled, and he has a distinct body odor. Which treatment goal is the priority for this​ client? The client will deny hallucinations. The client will exhibit an increased attention span. The client will verbalize logical thought processes. The client will complete activities of daily living​ (ADLs) appropriately.

The client will complete activities of daily living​ (ADLs) appropriately.

A student nurse is writing a research paper about​ Vygotsky's theory of cognitive development. Which core element of this theory will the student include in the​ paper? The mind is always evolving. The influence of culture is central to human development. There are structured developmental stages. The mind is a computational system.

The influence of culture is central to human development.

The nurse on the unit hears other nurses complaining about the nurse manager and how the unit is run. The nurse knows that in order to help resolve this​ conflict, she must try to understand the cause. Which factors may be causing conflict in this​ situation? ​(Select all that​ apply.) The nurse manager is relaying accurate information from management to the nursing staff at monthly meetings. The nurse manager is not keeping promises regarding staffing issues. The nurse manager is not using an effective leadership style. The staff nurses are being resistant to changes that the nurse manager is implementing. The nurse manager is not communicating effectively with the staff nurses.

The nurse manager is not keeping promises regarding staffing issues. The nurse manager is not using an effective leadership style. The staff nurses are being resistant to changes that the nurse manager is implementing. The nurse manager is not communicating effectively with the staff nurses.

A client​ states, "I just love coming to this​ clinic; everyone treats each other with such​ respect." Which scenario does not reflect a collegial relationship between the nurse and the​ physician? The physician asks the nurse her opinion regarding the​ client's condition. The nurse retakes a​ client's blood pressure after the physician takes it in order to get​ "the correct​ reading." The nurse tells the physician the client needs pain​ medication, and the physician writes the order. The physician and the nurse manager make rounds on all patients in the unit.

The nurse retakes a​ client's blood pressure after the physician takes it in order to get​ "the correct​ reading."

A nurse is assessing Andrew​ Parson, a​ 37-year-old client with cerebral​ palsy, admitted to the hospital with a broken tibia after being hit by a car as he crossed the street. Mr. Parson has significant communication difficulties and his speech is very difficult to understand. How can the nurse evaluate Mr.​ Parson's cognitive​ functioning? Try to use such assistive devices as a communication board to help assess Mr.​ Parson's functioning. Request a psychiatric​ consultation, because a mental status exam requires psychiatric skills. Assume that Mr.​ Parson's severe speech problems indicate cognitive impairment. Attempt to assess cognitive functioning in a client with severe communication limitations.

Try to use such assistive devices as a communication board to help assess Mr.​ Parson's functioning.

A nurse is preparing a presentation about schizophrenia. Which comorbid condition of schizophrenia needs to be​ addressed? Select all that apply. Type 2 diabetes mellitus Cancer ​Obsessive-compulsive disorder Attention deficit hyperactivity disorder​ (ADHD) Addiction

Type 2 diabetes mellitus ​Obsessive-compulsive disorder Addiction

Which factors increase an individual​'s chances of becoming a victim of​ violence? Select all that apply. Vulnerability factors Predisposing factors Protective factors Precipitating factors Risk factors

Vulnerability factors Predisposing factors

Michael is a​ 23-year-old client who is seen for treatment of a personality disorder. Which finding during the nursing assessment supports this​ diagnosis? -Weak sense of self -Severe mood swings -Depressed mood -Fear of specific objects

Weak sense of self

As you are preparing Mr. Mercer for​ discharge, your teaching plan includes strategies to help him manage his symptoms. Which strategies would you recommend to help him manage the side effects of benztropine​ (Cogentin)? Select all that apply. Wear sunglasses when outside. Develop reminders for taking his medication. Carry​ sugar-free hard candy or gum. Take a class in relaxation or meditation. Place a rubber or plastic cover on his pillow.

Wear sunglasses when outside. Carry​ sugar-free hard candy or gum. Take a class in relaxation or meditation.

The nurse is providing care to a pediatric client who is the victim of an assault that occurred on the way home from the store. Which factors may have caused the client to become the victim of​ assault? Select all that apply. Weekends Consumption of alcohol Unequal power in social interaction Good relationship with neighbors Winter months

Weekends Consumption of alcohol Unequal power in social interaction

A​ 2-year-old is brought to the pediatric clinic with an upper respiratory infection. After assessing the​ child, the nurse suspects that this child may be a victim of child abuse. Which is a physical sign that usually indicates child​ abuse? Diaper rash Scraped and scabbed knees Welts or bruises in various stages of healing on the child​'s back A few bruises on shins

Welts or bruises in various stages of healing on the child​'s back

Following your interview with Mrs. Martinez and​ Isabella, child protective officials ask you to provide an assessment on Mrs. Martinez.​ Specifically, the child protective officials want to know whether you got the sense that Mrs. Martinez was a danger to Isabella due to negligence. What is the most appropriate way for you to​ respond? You tell the officials that Mrs. Martinez is a great​ mother, because you​ don't want to see Isabella taken away from her. You tell the officials that Mrs. Martinez seems like a horrible parent for having moved with Isabella to her​ brother?s home. You tell the officials that you cannot reveal the information on the patient and the​ patient's mother, due to HIPAA. You tell the officials of the facts that you collected from your​ interview, such as that Mrs. Martinez claimed to be unaware of the abuse. You also note that Mrs. Martinez did not seem to know a lot about child​ abuse, which raised some concerns.

You tell the officials of the facts that you collected from your​ interview, such as that Mrs. Martinez claimed to be unaware of the abuse. You also note that Mrs. Martinez did not seem to know a lot about child​ abuse, which raised some concerns.

Which components should be included in all nursing interviews of clients with suspected alterations of​ self? Select all that apply. -Specific​ self-image -Global ideal self ​-Self-awareness ​-Self-concept ​-Self-esteem

​-Self-awareness ​-Self-concept ​-Self-esteem

Which alterations of the components of self can cause the development of personality​ disorders? Select all that apply. -Public self ​-Self-awareness ​-Self-esteem ​-Self-concept -Real self

​-Self-awareness ​-Self-esteem ​-Self-concept

The home care nurse is talking to an entire family when caring for their oldest​ member, an​ 88-year-old client with multiple health issues. The rest of the family includes a​ 48-year-old, a​ 28-year-old, an​ 18-year-old, and an​ 8-year-old. Which individuals are in age groups less likely to report or admit to being the victims of​ violence? Select all that apply. ​28-year-old ​88-year-old ​18-year-old ​48-year-old ​8-year-old

​88-year-old ​8-year-old

An​ OB-GYN nurse at a prenatal clinic listens as Tonya​ Jacobs, a​ 17-year-old pregnant​ woman, talks about her boyfriend. Tonya​ says, "He beat up his​ ex-wife a lot of​ times, but so​ far, he​ hasn't done more than yell at​ me." What feature of the situation is evidence that the young woman is at high risk of​ violence? ​Client's pregnancy ​Boyfriend's previous behavior ​Client's age ​Boyfriend's divorce

​Boyfriend's previous behavior

​Nancy, a nurse in the​ ICU, has been avoiding talking to her​ co-worker, Jim, about the subject of yearly evaluations. Nancy received a substantial raise with her yearly​ evaluation, and Jim did not. Jim has been complaining to Nancy in the break room and making negative comments about their manager and other coworkers since the evaluations. He​ complains, "I​ don't see how anyone got a pay raise if I​ didn't, because I am the best at what we​ do!" What type of conflict is Nancy​ experiencing? ​Covert, interpersonal ​Overt, intrapersonal ​Covert, intrapersonal ​Overt, interpersonal

​Covert, interpersonal

Part of preventing child abuse has to do with being aware of the warning signs of an​ at-risk abuser. If you had been the school nurse at​ Joey's school, which factors might have alerted to you that Joey was at risk for​ abuse? Select all that apply. ​Joey's dad being a single parent ​Joey's dad being of a certain age ​Joey's visible frailty ​Joey's dad recently losing his job ​Joey's dad?s addiction to alcohol

​Joey's dad being a single parent ​Joey's visible frailty ​Joey's dad recently losing his job ​Joey's dad?s addiction to alcohol

The nurse is preparing to assess a client for cognitive impairments. Which tool does the nurse plan to use during the nursing assessment of this​ client? ​Mini-Mental State Examination​ (MMSE) Minnesota Multiphasic Personality Inventory​ (MMPI) Rorschach Wechsler Adult Intelligence Scale​ (WAIS)

​Mini-Mental State Examination​ (MMSE)

Which biologically related factors are connected to fear and aggression and the pathophysiology of assault and​ homicide? Select all that apply. Loud noise ​Sympatho-adrenomedullary system Frustration Fight or flight response Alcohol

​Sympatho-adrenomedullary system Fight or flight response Alcohol

The school nurse is assessing a​ third-grade child for symptoms of sexual abuse. Which behavioral manifestations support the possibility of sexual​ abuse? ​Hyperactivity, stuttering, and isolating self from peers on the playground ​Thumb-sucking, isolating self from peers on​ playground, and excessive fear of strangers ​Stuttering, impulsivity, and being the team leader when playing games with peers ​Enuresis, impulsivity, and decline in school performance

​Thumb-sucking, isolating self from peers on​ playground, and excessive fear of strangers

A nurse is working in an emergency department and is being trained on diagnostic tests used for various cases of abuse. Which diagnostic tests should be included for​ physical, not​ sexual, abuse? Vaginal swabs HIV testing STD testing ​X-rays

​X-rays

A student nurse asks an experienced nurse for an example of a task that might help evaluate a client​'s cognitive functioning. Which is an appropriate response by the second​ nurse? "Who were the last two presidents of the United ​States?" "Do you ever see objects or hear voices that other people do ​not?" "If you won​ $10,000, how would you spend ​it?" "Count by fives from 0 to 100."

"Count by fives from 0 to 100."

Which statement by the nurse is most appropriate for a male victim of rape who asks why an anal swab is​ required? "The test is simple and will not hurt​ you, and the doctor needs to have this test completed." "I am just checking for sexually transmitted infections." "This is part of the rape​ kit, and I need to perform this test." "The swab can collect DNA to identify the attacker and also check for sexually transmitted infections."

"The swab can collect DNA to identify the attacker and also check for sexually transmitted infections."

Which laboratory test indicates the nutritional deficiency of anemia in a client with anorexia​ nervosa? -Hormone studies -Urinalysis -Comprehensive metabolic panel​ (CMP) -Transferrin

-Transferrin

Which complementary therapy may be considered in the treatment of a client with an eating​ disorder? Select all that apply. -Herbs -Yoga -Chamomile tea -Acupuncture -Biofeedback

-Yoga -Chamomile tea -Acupuncture -Biofeedback

The nurse is providing care for a pregnant woman and her husband who just learned that their baby may have Down syndrome. The couple asks the nurse what this condition means. Which response by the nurse is the most​ appropriate? "This condition occurs as a result of maternal substance abuse." "This condition occurs as the result of a traumatic head injury." "This condition occurs due to alcohol consumption prior to pregnancy." "This condition occurs because of extra genetic material in chromosome 21."

"This condition occurs because of extra genetic material in chromosome 21."

The nurse is conducting a mental status interview with a new client. Which questions are useful as part of the assessment​ process? Select all that apply. "Do you enjoy ​exercising?" "What day of the week is ​today?" "Where did you go to high ​school?" "Can you count by 5s from 0 to ​100?" "What is your ​name?"

"What day of the week is ​today?" "Where did you go to high ​school?" "Can you count by 5s from 0 to ​100?" "What is your ​name?"

The nurse educator is discussing intellectual disability with a group of students in the classroom environment. Which statement made by a student indicates correct understanding of the criterion of intellectual​ disability? "Clients with ataxia are intellectually disabled." "Clients who exhibit echolalia are intellectually disabled." "Clients who score below 70-75 on an IQ test are considered intellectually disabled." "Clients with delirium that occurs after the age of 50 are intellectually disabled."

"Clients who score below 70-75 on an IQ test are considered intellectually disabled."

The nurse is providing home care instruction for a client recently diagnosed with Alzheimer disease​ (AD). Which statement by the client indicates the need for further​ instruction? "I will make sure my wife asks for assistance if my care becomes overwhelming." "I will restrict my fluid intake because it is known to cause symptoms to worsen." "I will monitor my diet and eat foods that are nutritious." "There are community resources that can help me and my family as the disease progresses."

"I will restrict my fluid intake because it is known to cause symptoms to worsen."

The nurse is providing discharge instructions to a client who is recovering from a stab wound. Which statement from the client indicates the need for further​ instruction? "I will call the healthcare provider for a​ follow-up appointment tomorrow." "I will call my healthcare provider if my pain becomes worse." "I will stop taking my antibiotic as soon as I am no longer in pain." "I will do my leg exercises daily as instructed by my physical therapist."

"I will stop taking my antibiotic as soon as I am no longer in pain."

The mother of identical twin sons is asking the nurse questions about schizophrenia. One son has just been diagnosed with schizophrenia at age​ 17, and the mother is concerned about the other son​'s risk of developing the condition. Which is an appropriate response by the​ nurse? "Don​'t worry. He​'d already have been diagnosed if it were a problem." "No one knows the risk factors for schizophrenia." "Siblings have a higher risk of developing schizophrenia." "There are no genetic links in schizophrenia."

"Siblings have a higher risk of developing schizophrenia."

A nurse is explaining a​ double-bind situation to a group of new nurses. How should the nurse best explain this theory of​ schizophrenia? "The double bind is linked to poor bonding between infant and mother due to the mother​'s anxiety." "The double bind refers to chemical imbalances in the brain." "The double bind is a form of distorted communication between parent and child." "The double bind is related to poor communication between siblings."

"The double bind is a form of distorted communication between parent and child."

You are caring for Ms.​ Hernandez, a young woman who was recently raped. Ms. Hernandez is in shock and disbelief. When you try to give her antibiotics per the healthcare​ provider's order, she refuses to take them. Which is the best response to Ms.​ Hernandez's refusal to take​ medication? ​"It is not necessary for you to take​ medication." ​"The medication will help you forget the​ trauma." ​"The medication will help treat possible​ STDs." ​"The medication will prevent​ pregnancy."

"The medication will help treat possible​ STDs."

Family members are questioning a nurse about their​ mother's postoperative confusion. They​ ask, "Is our mother developing dementia from the​ anesthesia? She was thinking so clearly before the​ surgery." Which response by the nurse is the most appropriate to the​ family? ​"Your mother might have been developing mild dementia prior to​ surgery, and the anesthesia accelerated the​ progression." ​"It is not uncommon for dementia to begin after anesthesia in an older​ adult." "Your mother is experiencing postanesthesia​ delirium, which should clear as soon as she is completely recovered from the​ anesthesia." ​"Yes, your mother is experiencing postanesthesia​ dementia, which is completely reversible. She will recover in a few​ weeks."

"Your mother is experiencing postanesthesia​ delirium, which should clear as soon as she is completely recovered from the​ anesthesia."

Sally asks the nurse whether she should be concerned that her​ 68-year-old mother, who recently​ retired, is experiencing memory​ problems; seems unusually​ restless; and loses her temper frequently. Sally wants to know whether this change is a normal part of the aging process. What should the nurse tell​ Sally? ​"Don't worry. Memory loss is a normal part of​ aging." ​"Your mother should be evaluated for possible cognitive​ changes." ​"If your mother changes her eating​ patterns, these symptoms will probably​ end." ​"Your mother will probably return to normal once she has had time to adjust to​ retirement."

"Your mother should be evaluated for possible cognitive​ changes."

The nurse is providing care to a client who is diagnosed with delirium. Which assessment finding supports the client​'s ​diagnosis? Lack of ability to remember childhood anecdotes Sleeping heavily night and day Obsessive correctness and efficiency with tasks Desire to discuss​ his/her opinion on why delirium started

**Lack of ability to remember childhood anecdotes

The nurse is caring for a client with Alzheimer disease​ (AD). Which assessment findings does the nurse expect while caring for this​ client? Select all that apply. Tachycardia Trouble finding the right name for an object Hypotension Gradual behavior changes if the nurse was to care for this patient over a course of time. Confusion that occurs over a matter of hours.

**Trouble finding the right name for an object **Gradual behavior changes if the nurse was to care for this patient over a course of time.

The nurse is caring for a client diagnosed with a personality disorder. Which intervention is not appropriate for this​ client? -Allowing the client to keep a disposable razor at the bedside -Establishing a contract to attend one group therapy session per day -Refusing to share confidential information with another client -Identifying manipulative traits during free time

-Allowing the client to keep a disposable razor at the bedside

The nurse is reviewing the plan of care for a client who causes harm to himself by​ self-mutilation. Which evaluation statement indicates that the plan of care has been​ successful? -The client has remained free from injury during the hospital stay. -The client has not been violent toward others during the hospital stay. -The client exhibits fear of new people. -The client is scheduled for discharge in 2 days.

-The client has remained free from injury during the hospital stay.

A college student is seen in the emergency department following an incident of date rape. The nurse documents that during her assessment of the​ student, the student describes the entire chain of events with a blank facial expression. She ends her comments by​ saying, "It​'s like it didn​'t happen to me at​ all." Which order will the nurse expect for this​ client? SSRIs Antibiotics Narcotics NSAIDs

Antibiotics

​Claire, a nurse working on a​ medical-surgical unit, knows that everyone does not respond to conflict in the same way. What is the best way for Claire to manage potential​ conflict? Collaboration Accommodation Avoidance Competition

Collaboration

A nurse manager is working in the emergency department and is required to make assignments based on priority. Which clients would require priority care based on their initial assessment​ findings? Select all that apply. A client who is exhibiting violent behavior A client who is splinted for a femur fracture A client who is having difficulty breathing A client with a bullet wound to the abdomen A client who is crying and distraught

A client who is exhibiting violent behavior A client who is having difficulty breathing A client with a bullet wound to the abdomen

The nurse is prioritizing care for clients who have been assaulted during a mass shooting at a local mall. Which client will require priority care based on assessment​ findings? A client with a bullet wound to the throat A client with abdominal bruising A client with an open stab wound to the forearm A client with an open fracture of the femur

A client with a bullet wound to the throat

The​ nurse-physician relationship is the cornerstone of client care. In order to meet the needs of the​ client, what types of relationships between the nurse and physician must be​ fostered? ​ Select all that​ apply. Collaborative Personal Legal Collegial Social

Collaborative Collegial

What is the purpose of the focused assessment by sonography in trauma​ (FAST) test? Assessing level of consciousness Measuring response to pain Finding blood in body cavities Screening for antibodies

Finding blood in body cavities

The nurse is orienting a novice nurse to the intensive care unit​ (ICU). When assessing​ clients, which items might contribute to the development of​ delirium? Select all that apply. The client has a history of cerebral atherosclerosis. A client is admitted after a motor vehicle crash with a blood alcohol level of​ 0.25%. A client is awakened for frequent assessments and treatment. A client experiences unrelieved pain. A​ client's MRI shows atrophy of the hippocampus.

A client is admitted after a motor vehicle crash with a blood alcohol level of​ 0.25%. A client is awakened for frequent assessments and treatment. A client experiences unrelieved pain.

A client who is the victim of rape arrives in the emergency department. Once the client​'s safety is​ ensured, the nurse begins the physical examination. The nurse may find which of the following injuries from being​ restrained? Select all that apply. Bruising on the ankles Burns on the wrists Broken fingers Internal injuries Bruising around the neck

Bruising on the ankles Burns on the wrists Bruising around the neck

The nurse manager is dealing with conflict on the​ medical-surgical unit. Which situations reflect primary sources of​ conflict? ​(Select all that​ apply.) A nurse assistant who communicates assessment findings with the healthcare provider A nurse who places blame on the respiratory therapist for not administering a medication on time A nurse who is gossiping about a​ co-worker A nurse and a physical therapist who are collaborating to provide care to an elderly client A physician who does not believe a nurse practitioner can provide​ "on-call" care to clients

A nurse assistant who communicates assessment findings with the healthcare provider A nurse who places blame on the respiratory therapist for not administering a medication on time A physician who does not believe a nurse practitioner can provide​ "on-call" care to clients

Which is the best description of Alzheimer​ disease? Dyskinetic movements caused by disordered tonicity of muscle A temporary state of mental confusion and fluctuating consciousness An exaggerated feeling of physical and mental​ well-being A progressive deterioration of brain function

A progressive deterioration of brain function

Which response indicates interpersonal conflict on the neurology unit at the​ hospital? The nurse complains to the nurse manager about physician orders. A registered nurse and a nursing assistant are arguing over who should take clients to the bathroom. The registered nurses on the unit complain to management about their wages. A nursing assistant decides to take a job at the nursing home for more money.

A registered nurse and a nursing assistant are arguing over who should take clients to the bathroom.

Which type of treatment for schizophrenia involves assigning clients to a specific interprofessional team that delivers all services when and where the client needs​ them? Group therapy Assertive community treatment Family therapy Psychiatric rehabilitation

Assertive community treatment

The nurse is caring for a client who experienced a deep laceration to the arm as the result of an assault. The client is resting comfortably and is denying any pain but will need sutures to close the wound. Which pharmacologic therapy does the nurse anticipate for this client prior to​ suturing? Morphine Lidocaine Ibuprofen Penicillin

Lidocaine

A nurse at a geriatric clinic notices bruises on the arms and legs of a frail older client. If the bruises are caused by​ abuse, who might be possible​ perpetrators? Select all that apply. Prescriber of anticoagulants Client​'s spouse ​Meals-on-wheels volunteers Caregiver living in home Children visiting a parent

Client​'s spouse Caregiver living in home Children visiting a parent

What is assessed during a​ mini-mental state​ examination? Select all that apply. Orientation Memory Mood Vocabulary Judgment

Orientation Memory Mood Judgment

The nurse is talking with a client who just had a beautiful potted flower delivered. Suddenly the client starts to cry and stares out the window. The client has a history of abuse by her husband. Which response should the nurse include in the plan of care for this​ client? Assess if the client is having a flashback of previous abuse. Give the client some time and return later. Tell the client that the abuse was in the past. Tell the client to enjoy the flowers and that she will feel better in a little while.

Assess if the client is having a flashback of previous abuse.

The​ Mini-Mental State Examination​ (MMSE) is an assessment instrument that evaluates which function of the​ client? Anxiety Depression Cognitive Dementia

Cognitive

You are caring for Mrs.​ Xavier, a woman who is being treated for cuts and bruises to her arms and face. Mrs. Xavier reluctantly tells you that her husband caused the​ injuries, but she stresses that it was the only time he has ever hit her. While you are caring for Mrs.​ Xavier, her husband enters the room and asks her to forgive him. He promises never to hurt her again and gives her a large bouquet of flowers. The nurse recognizes this act as​ what? A demonstration of the​ husband's willingness to seek help and refrain from hurting his wife again A kind gesture to move toward a better future for the couple An attempt by the husband to continue controlling the client to prevent her from asking for help and to demonstrate he is​ repentant, to avoid punishment Extremely​ confusing, considering he just abused her and is now being so kind

An attempt by the husband to continue controlling the client to prevent her from asking for help and to demonstrate he is​ repentant, to avoid punishment

The nurse at a local hospital is working with a coalition of local organizations on violence prevention after a series of assaults and murders by members of youth gangs in the community. Which intervention is appropriate for the nurse to offer the​ community? Undercover police infiltration Anger management ​Hospital-based program Home visits

Anger management

Which common comorbid disorder should be assessed for when completing a health history of a client with​ schizophrenia? Select all that apply. Colorectal cancer Anxiety disorders Hyperthyroidism Mood disorders Cirrhosis

Anxiety disorders Mood disorders

The nurse is providing care to a client recently diagnosed with Alzheimer disease. Which medication does the nurse anticipate will be prescribed for this client to decrease the rate of cognitive​ decline? Haldol Zoloft Aricept Buspar

Aricept

A client diagnosed with schizophrenia is experiencing unrelenting anxiety. Which alternative therapy might the nurse recommend to the​ client? Aromatherapy Transcranial magnetic stimulation Electroconvulsive therapy​ (ECT) ​Omega-3 fatty acids

Aromatherapy

What are appropriate actions for a nurse to take to secure the safety of a trauma team and a client who is being treated for injuries sustained in an attempted​ homicide? Select all that apply. Ask law enforcement or security personnel to be present during treatment. Use chain of custody procedures for specimens. Do not clean the victim​'s hands. Ensure that the client is free of weapons. Cooperate with law enforcement and security personnel.

Ask law enforcement or security personnel to be present during treatment. Ensure that the client is free of weapons. Cooperate with law enforcement and security personnel.

The nurse is conducting an admission assessment for a client who is diagnosed with delirium of unknown cause. Which item will the nurse include during the health history of this client to determine a cause for the​ diagnosis? Assessing orientation Asking about drug and alcohol use Determining visual impairments Conducting a mental status exam

Asking about drug and alcohol use

Mrs. Pinkard wants to know what will happen to Joey in the long run.​ "Will he be psychologically damaged from this​ experience?" she asks you. What can you tell Mrs.​Pinkard? Select all that apply. Children must receive professional counseling because they must all be prescribed medications that will help them forget the experience. Because​ 95% of child abusers have been abused​ themselves, it is important for Joey to receive counseling in order to break the abusive cycle. Children who have been abused will go in and out of psychiatric hospitals for most of their lives. If children do not receive professional counseling after child abuse incidents they will seek revenge on their abusers. Children who have been abused can potentially develop mental health​ disorders, such as depression and​ anxiety, as well as develop low​ self-esteem or trust issues.

Because​ 95% of child abusers have been abused​ themselves, it is important for Joey to receive counseling in order to break the abusive cycle. Children who have been abused can potentially develop mental health​ disorders, such as depression and​ anxiety, as well as develop low​ self-esteem or trust issues.

Which is a goal of the nursing assessment for a client diagnosed with a personality​ disorder? -Drug identification -Family identification -Behavior identification -Work identification

Behavior identification

Which behaviors would the nurse correctly identify as forms of workplace​ bullying? ​Select all that​ apply. Being sarcastic Ridiculing Gossiping Encouraging Avoiding

Being sarcastic Ridiculing Gossiping

Which clinical therapy is appropriate for a client who suffers a gunshot​ wound? Blood transfusion Diagnostic tests to determine the source of bleeding Pin and rod placement Splint for immobilization

Blood transfusion

Jared​ Smith, age​ 17, is the victim of an assault and is admitted to the emergency department. His clinical manifestations are​ inflammation, swelling,​ pain, and bruising. Which etiology is the most likely cause of​ Jared's symptoms? Bone fractures due to a physical attack Abdominal stab wound Gunshot wound to chest Internal bleeding due to blunt force trauma

Bone fractures due to a physical attack

Which teaching point is appropriate for the client who is not oriented to time or​ place? The importance of fluids The use of community resources The use of clocks and calendars The importance of adequate sleep

The use of clocks and calendars

The nurse is performing diagnostic tests for a client who is the victim of rape. Which of the following ensures that evidence from the diagnostic tests can be used to convict the​ attacker? Double verification Evidence gathered by a doctor Sworn affidavit Chain of custody

Chain of custody

A nurse and physician are engaged in a heated discussion in the hallway of the unit. The nurse pokes the physician in the chest while making a point. What is the appropriate action by the staff nurse witnessing the​ event? Call the unit manager Call security Separate the two individuals physically Try to speak calmly with both individuals to deescalate the situation

Call the unit manager

The nurse is providing care to a client who is the victim of rape. Which action by the nurse offers the client emotional support during the assessment​ process? Select all that apply. Calling a friend or family member. Stating that the client invited the rape because of drug use. Offering counseling services. Providing access to a rape advocate. Assuming that pregnancy prevention medication is wanted.

Calling a friend or family member. Offering counseling services. Providing access to a rape advocate.

The nurse is providing care in the emergency department to a victim of rape. Which action is not part of the physical assessment of this​ client? Calling the police. Providing safety for the client. Offering counseling services. Assessing for wounds.

Calling the police.

The nurse is providing education to a client recently diagnosed with Alzheimer disease. The client​'s daughter wants to know which services are offered by the Alzheimer​'s Association. Which services will the nurse include in the​ response? Select all that apply. Treatment Caregiver respite guidance Support Education Legal referrals

Caregiver respite guidance Support Education Legal referrals

The nurse is caring for a client diagnosed with dementia. Which client behaviors support this​ diagnosis? Select all that apply. Anorexia Carphologia Dysphagia Akathisia Anomia

Carphologia Dysphagia Akathisia Anomia

Which are etiologic factors in the social learning theory of interpersonal​ violence, abuse, and​ neglect? Select all that apply. Children learn about violence from observation. Early life stress leads to mood and anxiety disorders in the individuals who are abused. The potentially abusive individual makes a conscious choice to abuse. The media expose children to many models of violence. Some communities value the subordination of women.

Children learn about violence from observation. The potentially abusive individual makes a conscious choice to abuse. The media expose children to many models of violence.

Shelley has been examined at the crisis center after a sexual attack. After the examination is​ completed, the nurse educates Shelley on the prescribed medication for a week of doxycycline hyclate. Shelley is being treated for which sexually transmitted​ infection? HIV Chlamydia Trichomoniasis Syphilis

Chlamydia

You are developing a nursing care plan for Mrs. Weddle. Which nursing diagnosis would have the highest​ priority? Client is at risk for injury. Client exhibits disturbed thought process. Daughter is at risk for caregiver strain. Client is anxious.

Client is at risk for injury.

A client is admitted after sustaining a severe physical assault during a robbery. The client has blood loss and numerous severe lacerations. Which goals are most appropriate to include in the initial plan of care for the​ client? Select all that apply. Client will demonstrate an effective breathing pattern. Client​'s blood pressure and heart rate will remain within normal limits. Client will be free of chronic pain. Client will be free of secondary injury related to trauma. Acute pain will be less than a 2 on a scale of 0 to 10.

Client will demonstrate an effective breathing pattern. Client​'s blood pressure and heart rate will remain within normal limits. Client will be free of secondary injury related to trauma. Acute pain will be less than a 2 on a scale of 0 to 10.

Although Joey is going to remain on your inpatient​ unit, eventually he will be discharged back into the community. When the time​ comes, what types of community resources and support services would be appropriate for someone in​ Joey's condition? Select all that apply. Community​ self-defense classes so Joey can learn how to protect himself Community support groups for children who are victims of abuse The local witness protection program to keep Joey safe from his dad A community behavioral health agency that provides mental health​ services, or legal and prosecution services and forensic interviewing for children like Joey Alcoholics​ Anonymous, where Joey can learn about his​ dad's drinking problem

Community​ self-defense classes so Joey can learn how to protect himself Community support groups for children who are victims of abuse A community behavioral health agency that provides mental health​ services, or legal and prosecution services and forensic interviewing for children like Joey

To what does the term "adaptive behavior" refer? Select all that apply. Mechanical skills Computer skills Conceptual skills Practical skills Social skills

Conceptual skills Practical skills Social skills

While educating Mrs. Weddles daughter about Alzheimer disease and​ dementia, she complains to the​ nurse, You just dont​ understand, my mother distorts the truth and makes up things. What is the best response to Mrs. Weddles​ daughter? Confabulation is a sign of middle stage Alzheimer disease. Clients with Alzheimer disease live in a fantasy world and do not know reality from fiction. Alzheimer disease clients do not know what they are saying. Her mother is experiencing an illusion.

Confabulation is a sign of middle stage Alzheimer disease.

Mr.​ Casales, a​ 77-year-old man with a history of Alzheimer disease​ (AD), is brought to his healthcare provider by his daughter. She expresses concerns that her​ father's AD seems to be getting worse. Mr.​ Casales's medical record reflects that during his last healthcare​ visit, he was diagnosed as having stage 4 AD. For which changes would you assess Mr. Casales to help determine if his AD has progressed to the next​ stage? Confusion regarding place and time Knowledge deficit of recent events Losing everyday objects such as keys and glasses Inability to remember names when introduced to new people

Confusion regarding place and time

You know that one successful therapeutic strategy for clients with eating disorders is a behavioral contract. Which element of a behavioral contract is essential for Takeishas​ treatment? -Taking all medications as prescribed and scheduled. -Refraining from purging by vomiting or laxative use. -Attending all group therapy sessions as scheduled. -Consuming all scheduled nutritional supplements as listed.

Consuming all scheduled nutritional supplements as listed.

The nurse wants to provide culturally sensitive care to the clients who are seen in the clinic for the treatment of mental disabilities. What cultural factors should a nurse consider when completing a cognitive assessment of these​ clients? Select all that apply. Traditional dress Culturally specific information Educational level Language proficiency Number of children

Culturally specific information Educational level Language proficiency

A nurse is assessing the victim of an automobile accident to check for possible injury to the brain and central nervous system. The client​'s family is relieved to learn that the client​'s neurological responses are normal. For which part of the ABCDE priority is the nurse​ checking? B C D E

D

Many rape victims suffer from a multitude of emotions in the aftermath of the attack. Which emotions are felt​ initially? Select all that apply. Disbelief Suicidal ideation Shock Anger Posttraumatic stress disorder

Disbelief Shock Anger

You are a nurse at a local inpatient psychiatric facility. You are conducting the initial assessment on Charles​ Mercer, a​ 40-year-old Caucasian​ male, who is being admitted for exacerbation of his chronic schizophrenia. He was first diagnosed at the age of​ 22, and this is his third admission for inpatient treatment. When you ask Mr. Mercer why he is​here, he tells you that he doesnt​ know, that the police picked him up at the grocery store and he has no idea why. He goes on to tell you that his​ friend, Clare, told him the cops just dont like him and are trying to put him in​ jail, so he begged them to come here instead. When you ask him who his friend is and where she is​ now, he gets​ agitated, points to the corner of the​ room, and​ screams, Shes over​ there, stupid! You observe that Mr. Mercer is dirty and unshaven and that his clothes are tattered and in disarray. He repeatedly taps his foot during the​ assessment, and several times you observe him rocking.According to the police​ report, the police picked up Mr. Mercer outside a local grocery store after the manager complained that he was coming in and out of the store yelling at customers and talking to himself in a loud voice. As you continue your​ assessment, you begin to document the symptoms of schizophrenia that you observe in Mr. Mercer. For which positive symptoms will you assess Mr.​Mercer? Select all that apply. Disorganized behavior Hallucinations Anhedonia Mania Delusions

Disorganized behavior Hallucinations Delusions

A nurse is providing information about tacrine hydrochloride for the spouse of a client diagnosed with Alzheimer disease​ (AD). Which items will the nurse include in the teaching​ session? Select all that apply. Tacrine hydrochloride will stop the progression of Alzheimer disease. Do not stop the medication without consulting the healthcare provider. Notify the healthcare provider if manifestations worsen. Observe the client for improvement in manifestations. The medication must be administered 1 hour before meals.

Do not stop the medication without consulting the healthcare provider. Notify the healthcare provider if manifestations worsen. Observe the client for improvement in manifestations. The medication must be administered 1 hour before meals.

As you review the common medications prescribed for Alzheimer​ disease, the health care provider is writing new orders for Mrs. Weddle. Which​ medication(s), alone or in​combination, would the health care provider likely consider for a client with Alzheimer​disease? Select all that apply. Donepezil​ (Aricept) Rivastigmine​ (Exelon) Mirtazapine​ (Remeron) Memantine​ (Namenda) Tacrine​ (Cognex)

Donepezil​ (Aricept) Rivastigmine​ (Exelon) Memantine​ (Namenda) Tacrine​ (Cognex)

The nurse is assisting in the physical examination of a client who is the victim of rape. Which action by the nurse does not involve collecting evidence that can be used in a criminal case to convict the​ attacker? Drawing blood for a CBC from the antecubital area. Combing the pubic area for stray hairs. Gathering a swab from the throat. Collecting semen from the vagina.

Drawing blood for a CBC from the antecubital area.

Bettina​ Weddle, an​ 80-year-old retired school teacher and​ widow, resides alone at home. She arrives at the family medical clinic with her​ daughter, Kara. Her daughter states she made the appointment with the health care provider because she is concerned about her mothers behavior lately. Kara reports her mother is becoming more and more forgetful and seems to have a short fuse one​ minute, and then is crying the next. Kara reports her mother is not changing her clothes for bed at night and has not been taking her evening bath as she has for years. When Kara visits her mother during the evening​ hours, she has been combative at times and does not want to take her bath. On Thanksgiving​ day, her mother put the turkey in the​ oven, but later they discovered her mother had forgotten to turn on the oven to bake it.You continue with the health history of the client. You notice Mrs. Weddle has a slight body odor and her shoes are unmatched. She​ states, There is nothing wrong with​ me! I am just forgetful in my old​ age, like everyone else gets at times. As she laughs her forgetfulness​ off, she tells​ you, Im not the only one in the group that has forgotten about our monthly womens Bible study. Her daughter​ replies, Mom, youve been going to that for 20​ years, thats not just something you forget. The symptoms Mrs. Weddle has been experiencing​ suggest: Select all that apply.​ Middle Alzheimer disease Early Alzheimer disease Delirium Dementia of the Alzheimer type​ (DAT) Late Alzheimer disease

Early Alzheimer disease Dementia of the Alzheimer type​ (DAT)

The nurse manager is discussing ways to prevent horizontal violence in the workplace with the nurses on the unit. Which action helps each nurse on the unit become partners in preventing workplace​ bullying? Educate others through unit presentations about the ramifications of workplace violence. Encourage gossiping about peers and other staff members. Ignore negative statements of others about nurses on the unit. Allow nurses who have been victims to approach and humiliate their abusers.

Educate others through unit presentations about the ramifications of workplace violence.

A nurse entrepreneur who is also a workplace bullying survivor is providing a seminar on the subject at a local hospital. What are appropriate objectives for the nurse entrepreneur to provide to the attendees of this seminar regarding the prevention of workplace​ bullying? Educating others about the ramifications of bullying Isolating the victim to provide a safe environment Gossiping about the abuser to make the victim feel better Developing acceptable codes of conduct Encouraging mandatory reporting

Educating others about the ramifications of bullying Developing acceptable codes of conduct Encouraging mandatory reporting

Which pieces of legislation provide protection for individuals with cognitive​ impairments? Select all that apply. Title IX of the Education Amendments of 1972 Education for Handicapped Children Act of 1975 Title VII of the Civil Rights Act of 1964 Developmental Disabilities Act and Bill of Right of 2000 Americans with Disabilities Act of 1990

Education for Handicapped Children Act of 1975 Developmental Disabilities Act and Bill of Right of 2000 Americans with Disabilities Act of 1990

Which term is used to describe the type of intimate partner violence that exists when there is no physical​ abuse, but one partner is humiliating and controlling the partner by lowering or restricting his movement or​ self-esteem? Emotional abuse Financial abuse Battering Sexual abuse

Emotional abuse

The nurse is caring for Carter​ Lee, age​ 15, who is at his​ mother's home recovering from a gunshot wound that resulted from an attempted homicide by a gang. Carter is making good progress in meeting treatment goals related to the wound. His pain is​ tolerable, his wound care is​ excellent, sensation and mobility are​ increasing, and he is participating in physical and occupational​ therapy, and taking his medication as prescribed. He expresses to you that he is afraid to leave his home and that he is angry with his assailant. What is the priority home care teaching topic you would discuss with this​ client? Instruct the client about wound care. Encourage the client to take medication as prescribed and report adverse effects. Encourage the client to seek counseling for personal growth. Encourage the client to seek​ follow-up treatment, such as physical and occupational​ therapy, as ordered by the physician.

Encourage the client to seek counseling for personal growth.

The nurse is providing education to the parents of a​ 21-year-old client recently diagnosed with schizophrenia. Which action assists in decreasing the client​'s likelihood of​ relapse? Voicing negative feelings using "you" language Setting limits regarding inappropriate behavior only when needed Providing an environment that stimulates the client Encouraging active listening

Encouraging active listening

Which technique helps a family successfully assist a client with​ schizophrenia? Select all that apply. Engaging in active listening. Using​ problem-solving skills. Setting appropriate boundaries. Implementing an effective communication style. Providing negative feedback.

Engaging in active listening. Using​ problem-solving skills. Setting appropriate boundaries. Implementing an effective communication style.

A​ 5-year-old girl who has been physically abused is having difficulty putting her feelings into words. Which nursing intervention best enables the child to express her​ feelings? Giving the child​'s drawings to the abuser Engaging in play therapy ​Role-playing Reporting the abuse to a prosecutor

Engaging in play therapy

Joey will be staying on your inpatient unit while his medical wounds​ heal, and while he is assessed and monitored for behavioral health conditions that may present as a result of the trauma. Based on the information you have​ collected, what are some of the primary prevention approaches that could have been taken to avert this incident from​ occurring? Select all that apply. Enhanced social support in the community Arresting​ Joey's dad after he showed up for work intoxicated Stress management education for​ Joey's dad Substance abuse treatment for​ Joey's dad Parenting education classes

Enhanced social support in the community Stress management education for​ Joey's dad Substance abuse treatment for​ Joey's dad Parenting education classes

What is the first priority for a nurse dealing with a child victim of​ violence? Let the child reveal the abuse. Develop a trusting relationship with the child. Avoid making negative comments about the perpetrator. Ensure the safety of the child.

Ensure the safety of the child.

Manny Garcia is a client hospitalized with schizophrenia who has severe hallucinations and catatonia. His health care provider has prescribed clozapine​ (Clozaril) for his symptoms and is surprised that he has shown no improvement. Which intervention should the nurse initiate in this​ situation? Increasing the​ client's therapy sessions Adjusting the​ client's dosage Ensuring the client has not​ "cheeked" his medication Changing the​ client's medication

Ensuring the client has not​ "cheeked" his medication

Amanda​ Hind, a​ 54-year-old woman with Down​ syndrome, and a resident of a group​ home, is diagnosed with metastatic pancreatic cancer. She tells the nurse that she​ doesn't want to end up in the hospital with all those machines attached. How should the nurse respond to Ms.​ Hind's statement? Tell Ms. Hind not to​ worry, that everything will be all right. Ask the supervisor of Ms.​ Hind's home to encourage her to accept aggressive treatment. Explain about advance directives and help Ms. Hind to formulate one that specifies her wishes. Change the subject so that Ms. Hind will be distracted and not think about her future.

Explain about advance directives and help Ms. Hind to formulate one that specifies her wishes.

A nurse case manager is working with a family that has been reported to authorities due to evidence of elder abuse. With which possible positive perspectives can the nurse view the crisis​ situation? Select all that apply. Families can be more motivated to adopt new behaviors. The crisis can be a window of opportunity for change. The crisis can lead to the involvement of lawyers and the police. The crisis can be a trigger for relocating older adults. Families can be more open to get help.

Families can be more motivated to adopt new behaviors. The crisis can be a window of opportunity for change. The crisis can be a trigger for relocating older adults. Families can be more open to get help.

During William​ May's admission to a psychiatric​ unit, he tells the nurse that Bill Gates personally delivered a tablet computer to his home and has called him weekly for the past 3 months. When completing the health​ history, what information should the nurse obtain from Mr. May to support the diagnosis of​ schizophrenia? Signs of a mood disorder Indications of malnutrition and poor​ self-care Family history of schizophrenia and other psychotic disorders Height and weight

Family history of schizophrenia and other psychotic disorders

The nurse is providing care to the victim of a rape that occurred over 1 year ago. Which symptom supports the diagnosis of posttraumatic stress disorder​ (PTSD)? Select all that apply. Flashbacks Tremor Anxiety Depression Nightmares

Flashbacks Anxiety Depression Nightmares

For which negative symptoms of schizophrenia will you assess Mr.​ Mercer? Select all that apply. Word salad Flat affect Apathy Echolalia Poverty of speech

Flat affect Apathy Poverty of speech

The nurse is reviewing the medical records of several clients. Which condition may have been revealed by genetic testing prior to​ conception? Learning disability Fragile X syndrome Schizophrenia Fetal alcohol syndrome

Fragile X syndrome

​Harry, age​ 19, suffered a head trauma in a motorcycle accident. After returning to​ school, Harry exhibits certain behavioral​ changes, including leaving the classroom with no explanation and taking his​ roommate's cell phone without asking permission. Based on​ Harry's behavior, which area of the brain does the nurse anticipate was affected by the head​ trauma? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Frontal lobe

A staff nurse educator is presenting an inservice to staff members regarding the risk of violence and healthcare workers. What factors will the educator include in the​ presentation? Select all that apply. Heathcare workers will care for perpetrators and victims when they are most vulnerable. Victims and perpetrators of violence being treated in healthcare agencies act out their frustrations. Chronic physiological activation in response to stress can cause an aggressive personality. Strong connections between​ aggression, fear, and stress are biologically based. Assault and murder typically leave the individual feeling powerless and angry.

Heathcare workers will care for perpetrators and victims when they are most vulnerable. Victims and perpetrators of violence being treated in healthcare agencies act out their frustrations. Assault and murder typically leave the individual feeling powerless and angry.

A school nurse is talking to a​ fifth-grade class about recognizing behavioral and psychological factors in themselves and their classmates that predispose them to violence. What characteristics should the nurse​ describe? Select all that apply. Living in a​ low-income community History of being bullied History of bullying others Depression Having siblings who are heroin addicts

History of being bullied History of bullying others Depression

Charles Dixon is a client with schizophrenia. Although he has been on​ medication, he still hears voices and is reluctant to tell the nurse what they say to him. He is clearly agitated and wants the voices to stop. What is the clearest risk associated with Mr.​ Dixon's disorder? Depression Homicidal thoughts and actions Substance abuse Victimization by others

Homicidal thoughts and actions

An adult client diagnosed with abdominal cancer is undergoing chemotherapy. The nurse comes to the client​'s room to monitor vital signs and discovers the client and spouse in an argument that is becoming loud and aggressive. What is the best response by the​ nurse? Why are you two yelling at each​ other? This is a ​hospital! I cannot allow you to yell at one another. Please leave if you cannot be civil to your spouse. I see you both are upset. One at a​ time, calmly, tell me how we can resolve this matter so we can continue the treatment. It doesn​'t matter what led to the​ argument; we have to finish the chemotherapy.

I see you both are upset. One at a​ time, calmly, tell me how we can resolve this matter so we can continue the treatment.

A nurse manager sends a memo to all staff nurses that they must have their BSN within three years or risk losing their job. Which response by the ICU RN indicates the nurse may be experiencing an intrapersonal​ conflict? When did this policy come ​out? Why are they making us go back to ​school? I will make better money at the nursing home. I have been thinking about going back to school.

I will make better money at the nursing home.

All of Mrs.​ Martinez?s questions make you realize that she may not have a lot of knowledge in the area of child abuse prevention. The fact that her​ daughter, Isabella, was sexually abused by Uncle Fernando for several weeks while Mrs. Martinez was unaware leads you to believe that Mrs. Martinez needs to be educated on prevention strategies. What can you tell Mrs. Martinez about preventing child abuse to reduce the possibility of another incident like this​occurring? It is important to teach children that only relatives are allowed to put their hands on them. It is important to teach children to never talk to strangers. It is important to teach children about sexual education and identify their​ ?private parts," while instructing them to never let others touch those parts of their bodies. It is important to teach children that they should always give relatives hugs and​ kisses, but nothing else.

It is important to teach children about sexual education and identify their​ ?private parts," while instructing them to never let others touch those parts of their bodies.

How is emotional abuse different from physical​ abuse? Select all that apply. It is seldom measured. It occurs without the victim​'s consent. It cannot be seen. It occurs because the caregiver failed to protect the victim. It is inflicted accidentally.

It is seldom measured. It cannot be seen.

Which nursing interventions may be appropriate for the client who is the victim of an​ assault? Select all that apply. Discourage the use of analgesics Keep the family informed of​ client's status Maintain​ client's airway Maintain tissue perfusion Allow client to discuss fears

Keep the family informed of​ client's status Maintain​ client's airway Maintain tissue perfusion Allow client to discuss fears

The nurse educator is teaching a group of students about the brain and asks the class to name the term for specialized cells in the brain. Which response indicates understanding by the​ class? Erythrocytes Exocrine cells Neurons Epithelial cells

Neurons

A novice nurse manager recognizes which situations indicate intergroup​ conflict? ​(Select all that​ apply.) Nurses in the ICU complain that nurses in the ED do not recognize stroke symptoms. Respiratory therapists complain that nurses should not increase or decrease oxygen levels for clients on oxygen. A group of nursing assistants complain that nurses sit at the nursing station too much. A physician complains that the nurses on the unit did not write his orders correctly. A nurse complains that the physical therapist did not work with her patient today.

Nurses in the ICU complain that nurses in the ED do not recognize stroke symptoms. Respiratory therapists complain that nurses should not increase or decrease oxygen levels for clients on oxygen.

The parents of a teenager are talking with the nurse in the urgent care clinic about the injuries their son sustained in a physical fight during his high school lunch hour. What can the nurse tell them about fighting in​ adolescence? Its prevalence is not known. It is due to the effect of hunger on teenagers. One third of high school students get into physical fights. It is an unexpected event in that age group.

One third of high school students get into physical fights.

The nurse is caring for a client with a history of schizophrenia for over 20 years. A participant in an assertive community treatment​ program, the client frequently stops taking his medications and becomes verbally and physically assaultive. Which intervention should the nurse include when planning​ care? Select all that apply. Setting limits to inappropriate client behavior Maintaining a safe environment for the client and staff members Monitoring for violent ideations Administering medications and assessing client response to medications Referring the client for occupational training

Setting limits to inappropriate client behavior Maintaining a safe environment for the client and staff members Monitoring for violent ideations Administering medications and assessing client response to medications

Isabella breaks her silence to tell you one​ word: Fernando. Mrs. Martinez asks what it means that Fernando sexually abused her daughter. You take a moment to educate Mrs. Martinez on what sexual abuse can include. You tell​ her, "Sexual abuse can mean many​ things, Mrs.​Martinez, and it​ doesn't always mean​ intercourse." Although there is no universal definition of sexual​ abuse, what is an appropriate and accurate definition that you can give to Mrs.​Martinez? Sexual abuse means any type of sexual activity that is physical. Sexual abuse means intercourse and​ oral-genital contact. Sexual abuse means intercourse and digital penetration. Sexual abuse means any type of sexual​ activity, and can also include events that did not result in physical contact.

Sexual abuse means any type of sexual​ activity, and can also include events that did not result in physical contact.

The nurse is providing care to a victim of rape. The rape occurred over a year ago. Which assessment findings are expected for this​ client? Select all that apply. Anxiety Sexual dysfunction Confusion Anger Eating disorders

Sexual dysfunction Anger Eating disorders

During your interview with​ Isabella, she reveals that the sexual abuse by Uncle Fernando has been going on for a few​ weeks?ever since they moved into his home. You ask Mrs. Martinez if she had any suspicion about​ Fernando's attempts on​ Isabella, to which she replies​ "No." However, Mrs. Martinez is overwhelmed with guilt about the fact that she​ didn?t know and feels she should have picked up on it. She​ asks, "What could I have looked​ for? There​ weren?t any​signs." What are some of the signs and symptoms you can explain to Mrs. Martinez that would indicate possible sexual abuse in a child of​ Isabella's age? That some children internalize the​ experience, but show fear around their perpetrators. That sometimes there​ aren't any​ noticeable, visible​ signs; every victim of sexual abuse responds differently. That crying and exhibiting inappropriate behavior is the only way to tell whether a child has been sexually abused. That there are physical indicators to look​ for, such as​ bruising, cuts, and the onset of pain in certain parts of the body. That nightmares and​ anxiety?such as when Isabella would take a​ bath?are possible symptoms of sexual abuse.

That some children internalize the​ experience, but show fear around their perpetrators. That sometimes there​ aren't any​ noticeable, visible​ signs; every victim of sexual abuse responds differently. That there are physical indicators to look​ for, such as​ bruising, cuts, and the onset of pain in certain parts of the body. That nightmares and​ anxiety?such as when Isabella would take a​ bath?are possible symptoms of sexual abuse.

Mrs. Martinez​ asks, ?Will my daughter be psychologically damaged from this​ trauma?? Although you are not a mental health care​ provider, and it is impossible to predict what kind of psychological impact this will have on​ Isabella, you can offer Mrs. Martinez some statistics about the effects that sexual abuse has on children. What might you tell Mrs. Martinez about the future​ effects? Select all that apply. The American Psychological Association says that children who talk about their sexual abuse to others who believe their report will be less traumatized than children who never talk about the abuse. All children who have been sexually abused will have poor relationships with others in the future. Approximately​ 95% of child abusers were abused​ themselves, but that this cyclical chain can be broken with the appropriate therapeutic interventions. Children who have been sexually abused never recover from the experience. Children who were sexually abused need to take medication to treat​ post-traumatic stress disorder​ (PTSD).

The American Psychological Association says that children who talk about their sexual abuse to others who believe their report will be less traumatized than children who never talk about the abuse. Approximately​ 95% of child abusers were abused​ themselves, but that this cyclical chain can be broken with the appropriate therapeutic interventions.

A client has sustained a chest wound as the result of a stabbing. The trauma team has inserted a chest tube to suction. What is the most appropriate goal for this​ client? The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 85%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 90%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 88%. The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 92%.

The client will demonstrate effective​ breathing, as evidenced by the​ regular, nonlabored​ respirations; clear, equal breath sounds to​ auscultation; and oxygen saturation of at least​ 92%.

Which options indicate successful achievement of client goals and outcomes for a client who has experienced an attempted​ homicide? Select all that apply. The client​'s airway remains patent. The client has benefitted from collaborative interventions. The client​'s blood pressure and heart rate remain within normal limits. The client verbalizes emotions and concerns. The client​'s goals and outcomes are formulated.

The client​'s airway remains patent. The client​'s blood pressure and heart rate remain within normal limits. The client verbalizes emotions and concerns.

A case management nurse is working with a familiar​ client, a proven victim of repeated and severe domestic abuse. The client has chosen to return for the third time to live with the abuser. What must the nurse remember in this frustrating​ situation? Select all that apply. The client​'s decisions should not be judged by the nurse. The client has the case manager​'s contact information. The client feels unable to leave an unsafe situation. The client will never make other living arrangements. The client​'s choice should be supported by the nurse.

The client​'s decisions should not be judged by the nurse. The client has the case manager​'s contact information. The client feels unable to leave an unsafe situation. The client​'s choice should be supported by the nurse.

A client is brought to the emergency department after she was discovered trying to break into her boss​'s apartment. The client explains that they are engaged and she simply lost her key. Her mother tells the nurse that for the last 2​ weeks, the client has insisted that her married boss is not really married and that they are making wedding plans. Why should the nurse consider a diagnosis other than​ schizophrenia? Select all that apply. The client demonstrates poor​ self-care. The client​'s symptoms have lasted less than 1 month. The client​'s thought patterns demonstrate loose associations. The client​'s speech is perseverative. The client​'s delusions are the only psychotic symptom.

The client​'s symptoms have lasted less than 1 month. The client​'s delusions are the only psychotic symptom.

A nurse is assessing an older adult client who was being abused and neglected. The nurse should assess the client for which​ characteristics? Select all that apply. Trauma to sexual organs Malnutrition Withdrawn behavior Chronic fatigue Bruises or burns

Trauma to sexual organs Malnutrition Withdrawn behavior Bruises or burns

What are some of the environmental factors that influence the risk of violence in young​ people? Select all that apply. Becoming easily frustrated Traumatic brain damage Socioeconomic conditions Intense anger Frequent loss of temper

Traumatic brain damage Socioeconomic conditions

A forensics nurse is preparing a presentation to educate members of the community to decrease their risk of being involved in a violent crime. Which locations will the nurse include in the presentation that place an individual at a higher risk of assault or​ homicide? Select all that apply. Suburbs Rural area Urban area Southern states Economically challenged area

Urban area Southern states Economically challenged area

Isabella Martinez is a​ 6-year-old girl of Hispanic descent. Her​ mother, Carmella​ Martinez, is a​ 25-year-old, single working mother who manages the night shift at a local restaurant.​Recently, Mrs. Martinez and her daughter had to move into Mrs.​ Martinez's brother's​ house, so that he could watch Isabella while she works at night. Since the​ move, Mrs. Martinez has noticed that Isabella is quieter than normal. She​ doesn't play with her dolls as much as she used​ to, and she seems to be more​ withdrawn, especially around​ Fernando, her brother. Mrs. Martinez figures it just has to do with all of the recent​ changes, and that Isabella will eventually grow out of this new​ phase. After a couple of​ months, Mrs. Martinez notices that Isabella has become increasingly uncomfortable during bath time. She yells and cries when she has to take her clothes off to bathe. One​ evening, during bath​ time, Mrs. Martinez notices two bruise marks on the inside of​ Isabella's thighs. She asks Isabella how she got the​ bruises, and Isabella withdraws​again, staying silent. Mrs. Martinez is worried that something is terribly wrong with her daughter. Being that it is​ nighttime, she rushes Isabella to the​ children's crisis​ unit, because it is the only facility that is​ open. Isabella is examined by the health care provider on duty and a SANE​ nurse, who is trained in performing forensic examinations on sexually abused individuals. They conclude that Isabella is a victim of sexual assault. As a nurse on​ duty, you are responsible for beginning the interview with Isabella and her mother. Mrs. Martinez feels a little better knowing that Isabella has a chance of recovery.​ ?What types of things will a therapist or behavioral health care professional do with Isabella to help​her?? Although behavioral health is not your​ specialty, your nursing education and training provided you with information on what types of interventions are necessary for child abuse victims. What kinds of therapeutic interventions can you discuss with Mrs.​ Martinez? Select all that​ apply. Using doll play as a means of therapeutically expressing herself and her experiences Activities to help Isabella learn how to build trust in others Having Isabella describe the events in detail to flush the memories out of her system Creating a supportive environment for​ Isabella, including community support and spirituality or religious support Activities to help Isabella build her​ self-esteem

Using doll play as a means of therapeutically expressing herself and her experiences Activities to help Isabella learn how to build trust in others Creating a supportive environment for​ Isabella, including community support and spirituality or religious support Activities to help Isabella build her​ self-esteem

A nurse is conducting a nursing assessment interview of an individual with unexplained rib fractures. To check whether the person is a possible victim of domestic​ abuse, the nurse​ asks, "Has your partner ever struck you when feeling ​angry?" Which word in the nurse​'s phrasing of the question shows​ consideration? Using the word "struck" Using the word "ever" Using the word "angry" Using the word "partner"

Using the word "ever"

The community health nurse is conducting a presentation regarding rape. Which common myth associated with rape should the nurse discuss in the​ presentation? Select all that apply. Victims deserved the rape because they were dressed provocatively. Victims deserved the rape because of where they were located. African American women welcome all forms of sexual contact because of their race. Women are never the perpetrators of rape. Men are never the victims of rape.

Victims deserved the rape because they were dressed provocatively. Victims deserved the rape because of where they were located. African American women welcome all forms of sexual contact because of their race.

Mrs. Martinez looks at Isabella and shakes her​ head, starting to cry.​ ?It is because she is a pretty little girl that this​ happened.? While you​ don?t want to come across as​ argumentative, you feel the need to correct Mrs. Martinez in her line of thought. Victims of child abuse are not always little​ girls, and they are not always​ pretty, so you​ don?t want her to be misinformed. What can you tell Mrs. Martinez about the victims of child​ abuse? Victims of child abuse are always of a particular socioeconomic background. Victims of child abuse are always girls or boys under the age of 10. Victims of child abuse can be girls or boys from any socioeconomic​ background, culture, or religion. Victims of child abuse are always children who are cute or pretty.

Victims of child abuse can be girls or boys from any socioeconomic​ background, culture, or religion.

A pediatric nurse is conducting a health history on a newly admitted child. The nurse includes the fact that the child​'s family has been involved in a cycle of violence. What meaning could the nurse be​ conveying? The child​'s parents have never committed violent acts. Violence has occurred across multiple generations. Violence occurs unexpectedly and randomly in the child​'s family. The child has​ self-abusive behaviors.

Violence has occurred across multiple generations.

The etiologies of interpersonal​ violence, abuse, and neglect relate to several different theories. Which explanation best describes the social learning​ theory? The cause of violence lies in the personality of the individual who commits abuse. Violence related to abuse and neglect is a learned behavior. The tendency to​ abuse, neglect, and become violent toward others is a result of genetic considerations and distortion in neurotransmitters. Some​ families, cultures, and communities value the subordination of women through power and privilege.

Violence related to abuse and neglect is a learned behavior.

Which injuries to a victim of assault are most likely to require the use of computed tomography​ (CT) as a diagnostic​ test? Spinal cord injury Internal bleeding Fracture Abdominal injury

internal bleeding

Which client statement indicates the victim of rape has not reached the reorganization stage of​ healing? ​"I met a new man and went out on a date with​ him." ​"I can't stop crying when I think about the​ attack." ​"I go to the crisis center every other week for group​ sessions." ​"I can talk to others about the attack and am not overwhelmed​ anymore."

​"I can't stop crying when I think about the​ attack."

A nurse is providing care for a client who is suspected to have Alzheimer disease​ (AD). The client has numerous tests scheduled. The client asks the nurse why there are so many tests ordered. Which response by the nurse is the most​ appropriate? ​"The tests are necessary to determine what is causing Alzheimer​ disease." ​"Alzheimer disease is diagnosed in part by ruling out other diseases that affect​ memory." ​"The tests are used to identify which gene is causing Alzheimer​ disease." ​"There are a number of diagnostic tests that are needed to accurately diagnose Alzheimer​ disease."

​"Alzheimer disease is diagnosed in part by ruling out other diseases that affect​ memory."

Ms. Gray is a​ 42-year-old client who presents to her healthcare provider for a routine physical examination. While you are collecting Ms.​ Gray's history, she tells you that her elderly mother has just been diagnosed with Alzheimer disease​ (AD). Which statement would you make to Ms. Gray when she asks you what she can do to help protect herself from the​ disease? ​"There is nothing you can do to protect yourself from Alzheimer disease if you have a close relative with the​ disease." ​"Avoid heavy cigarette smoking and alcohol​ consumption." ​"Maintain a healthy weight and keep your blood sugar under​ control." ​"Avoid a diet that is rich in vitamin E and​ omega-3 fatty​ acids."

​"Avoid heavy cigarette smoking and alcohol​ consumption."

A nurse manager has to manage intergroup conflict between both the pediatric and labor and delivery​ (L&D) units. The nurse manager realizes which responses are examples of covert conflict among the staff​ nurses? ​(Select all that​ apply.) ​"What do we need to do to resolve these​ issues?" ​"Are we going to lose our​ jobs?" ​"We told the nurses on the​ L&D unit that we needed to discuss our issues over​ lunch." ​"Conflict? What​ conflict? You have to work to have​ conflict, and most of our nurses have been out​ sick." ​"We heard that the nurses on the pediatric unit have been discussing our issues on other​ units."

​"Conflict? What​ conflict? You have to work to have​ conflict, and most of our nurses have been out​ sick." ​"We heard that the nurses on the pediatric unit have been discussing our issues on other​ units."

The nurse is caring for a client who is the victim of rape. The client refuses the emergency contraception offered to her. Which statement by the nurse is the most appropriate regarding the window of time during which emergency contraception is most​ effective? ​"Emergency contraception is most effective if administered within 10​ days." ​"Emergency contraception is most effective if administered within 1​ month." ​"Emergency contraception is most effective if administered within 3​ days." ​"Emergency contraception is most effective if administered within 1​ week."

​"Emergency contraception is most effective if administered within 3​ days."

In the emergency​ department, a nurse is handing a doctor sterile supplies to suture several young people who reportedly got into a​ gang-related altercation. Which statement by the nurse best shows the need for more education for the​ nurse? ​"Gang members always lie about the cause of their​ injuries." ​"Gang members protect each ​other's ​identity." ​"I should not have negative preconceived ideas about​ gangs." ​"Gang culture values violence as a rite of​ passage."

​"Gang members always lie about the cause of their​ injuries."

The nurse has just completed a seminar presenting strategies to prevent rape. Which participant statement indicates that more instruction on rape prevention is​ needed? ​"I make sure that I look around the parking lot to make certain no one is near before I head to my​ car." ​"I never go to the clubs by myself and I never leave by​ myself." ​"I am only running to the laundromat across the street. I will be okay​ tonight." ​"I will leave the classroom and walk to my car with a couple of​ friends."

​"I am only running to the laundromat across the street. I will be okay​ tonight."

The nurse is conducting an admission assessment for a client diagnosed with late stage Alzheimer disease​ (AD). Which statement by the client​'s spouse indicates a need for further teaching regarding the progression of the​ disease? ​"My husband doesn​'t recognize me anymore. He​ can't sit or stand or control his bowels or urine. And he​ can't eat or swallow or talk. I am so grateful that the caregivers come to our home. He seems so​ peaceful." ​"I feel bad that I can no longer provide all the care my husband needs. I wish I could continue to be his caregiver.​ It's just too much for​ me." ​"I feel tired all the time. And I often feel guilty and angry. I​ don't understand it. My own health really needs to be secondary. I need to better organize my time so that I can get everything done each​ day." "I am having a hard time transitioning from being my​ husband's caregiver to being his advocate. I wish I could provide all of his care. I know that I cannot. I feel so bad that I have to move him out of our​ home."

​"I feel tired all the time. And I often feel guilty and angry. I​ don't understand it. My own health really needs to be secondary. I need to better organize my time so that I can get everything done each​ day."

You are caring for Mr.​ Davis, an​ 84-year-old man who has been hospitalized for malnutrition. You suspect that elder abuse may be responsible for Mr.​ Davis's condition, but when you ask him about the care he receives from his​ caregiver, he tells you he is afraid of what will happen if his caregiver finds out that he is complaining. Which is your best response to Mr.​ Davis? ​"You shouldn't be so afraid of what your caregiver will​ do." ​"It's necessary that I share what you tell me with your​ caregiver." ​"It would be better for you if I share what you tell me with your​ caregiver." ​"I will not share anything you tell me with your​ caregiver."

​"I will not share anything you tell me with your​ caregiver."

A rape counseling group offers support for rape survivors. Renee is attending one of the meetings and​ says, "I​ don't understand why I need to come to this​ group." Which response by the nurse is the most​ appropriate? ​"Medication is not as helpful for​ recovery, so we use support​ groups? ​"The group often takes charge of the​ victim's recovery​ process." ​"The group gives you a safe place to discuss your own individual​ experience." ​"If this group​ isn't right for​ you, maybe you should look for another​ one."

​"The group gives you a safe place to discuss your own individual​ experience."

You are caring for Mr.​ Mitchell, a​ 74-year-old client who is diagnosed with delirium after having an emergency appendectomy 2 days ago. Mrs.​ Mitchell, the​ client's wife, asks the nurse how this could have happened. Based on the assessment data​ collected, which response is most​ appropriate? ​"Your husband's history of heavy smoking is the most likely​ cause." ​"Your husband's uncontrolled blood pressure is causing the​ delirium." ​"This can happen with opioids that have been administered to control your​ husband's pain." ​"This is a normal part of aging. Your husband is just​ unlucky."

​"This can happen with opioids that have been administered to control your​ husband's pain."

Mrs. Matsuoka is a​ 68-year-old woman who was brought to her healthcare provider by her husband after he noticed that she was frequently forgetting familiar names and misplacing her keys. After an extensive​ examination, the healthcare provider diagnoses Mrs. Matsuoka with Alzheimer disease​ (AD). Mrs. Matsuoka asks you if there are any complementary therapies that she can use to help slow down the progression of her disease. Which reply would you provide to Mrs.​ Matsuoka? ​"St. John's wort helps improve memory for those with​ early-onset Alzheimer​ disease." ​"Zinc supplements are believed to support brain​ function." ​"Coenzyme Q10 is a naturally occurring substance in the body that has been found to inhibit the enzyme that breaks down​ neurotransmitters." ​"Huperzine A has been found to reverse the brain damage that occurs with Alzheimer​ disease."

​"Zinc supplements are believed to support brain​ function."

The community health nurse has been asked to give a presentation to a local group focused on healthy body image in teenage girls. Which statement by one of the teenagers indicates the need for additional​ teaching? -"My confidence should be based on my value as a human​ being, not the size of my clothes." -"I learned a lot about healthy eating and healthy portions today." -"I need to eat enough calories to meet the nutritional needs of my body." -"No matter​ what, it is important to be healthy by staying thin."

"No matter​ what, it is important to be healthy by staying thin."

The nurse is providing care for a client who may have a personality disorder. Which question will be most appropriate for the nurse to include in the client interview to help diagnose the client​'s personality​ disorder? -"Are you having trouble ​sleeping?" -"Have you recently experienced weight ​loss?" -"Have you had thoughts of​ violence?" -"Do you ever experience feelings of ​mania?"

-"Have you had thoughts of​ violence?"

The school nurse becomes concerned about a potential eating disorder when a member of the cheerleading squad is brought to the office following a syncopal episode during practice. Once the client has​ rested, the nurse inquires about the time she last had something to eat. The client​ responds, "I only eat dinner at night because I don​'t want to get fat." The nurse calculates the client​'s body mass index​ (BMI) as 19 and gathers additional information. Which client statement contributes to the nurse​'s concern that the client has anorexia​ nervosa? Select all that apply. -"If I eat too​ much, I use laxatives to balance it out." -"I know I need extra calories when I​'m training extensively." -"I don​'t think it​'s a big deal if I don​'t eat three meals a day. It​'s healthier to be skinny." -"I eat only 800 calories per day." -"I feel fat."

-"If I eat too​ much, I use laxatives to balance it out." -"I don​'t think it​'s a big deal if I don​'t eat three meals a day. It​'s healthier to be skinny." -"I eat only 800 calories per day." -"I feel fat."

Which statement by the nurse indicates an understanding of eating disorders and organ​ function? Select all that apply. -"Cardiovascular side effects of anorexia nervosa include tachycardia and hypertension." -"The client with an eating disorder may present with jaundiced skin tone." -"Easily bruised skin is a normal finding in a healthy individual." -"The client with bulimia nervosa will have no abnormal dental findings." -"An eating disorder can affect the integumentary​ system, leading to dry​ skin, brittle​ hair, and brittle nails."

-"The client with an eating disorder may present with jaundiced skin tone." -"An eating disorder can affect the integumentary​ system, leading to dry​ skin, brittle​ hair, and brittle nails."

The nurse is caring for a client who is suffering from extremely low​ self-esteem. In trying to assess the specific factors that are affecting the​ client's self-esteem, what factors would the nurse​ consider? Select all that apply. -Ethnicity -Gender -Age -Socioeconomic status -Level of education

-Age -Socioeconomic status -Level of education

The nurse is caring​ for17-year-old Michelle Appleton at an outpatient pediatric clinic. Michelle requires a complete physical prior to joining the high school cheerleading squad. Upon​ assessment, Michelle's nurse notes that Michelle has areas of decay on several teeth and​ Michelle's weight is less than​ 85% of normal.​ Michelle's mother privately tells the nurse that she is concerned because she suspects that her daughter is vomiting after meals and that she is not eating very much during the day.The nurse would consider that Michelle might be experiencing which alteration of​ self? -Rumination disorder -Anorexia nervosa -Pica -​Binge-eating disorder

-Anorexia nervosa

The nurse is completing an intake health questionnaire with a​ 20-year-old professional ballerina. The client has a body mass index of​ 17.5, blood pressure of​ 95/45 mmHg, and an irregular apical pulse. For which eating disorder should this client be​ screened? -Anorexia nervosa -Overexercising ​-Binge-eating disorder -Bulimia nervosa

-Anorexia nervosa

The nurse is performing the initial physical exam of a client who presented with a complaint of "feeling faint" when standing up. During the​ exam, the nurse notes​ emaciation, dry​ skin, and lanugo on the client​'s arms and shoulders. Which diagnosis should the nurse consider based on these​ findings? -Anorexia nervosa -Hyperthyroidism -Bulimia nervosa ​-Binge-eating disorder

-Anorexia nervosa

Through an assessment screening the nurse observes that a client is obsessed with​ weight, has an extreme fear of gaining​ weight, and admits to using laxatives and diuretics to lose weight. The nurse would consider that the client has which eating or feeding​ alteration? -Anorexia nervosa -Rumination disorder -Prader-Willi syndrome -Bulimia nervosa

-Anorexia nervosa

The nurse is working with a team of healthcare professionals to care for a client with a personality disorder. The team has collaboratively decided on pharmacologic therapy for the client. Which types of medications would the nurse expect to provide to treat the​ client's condition? Select all that apply. -Antidepressant -Anxiolytic -Anticonvulsant -Antipsychotic -Antispasmodic

-Antidepressant -Anxiolytic -Antipsychotic

The nurse is working with a team of healthcare professionals to care for a client with a personality disorder involving hallucinations. The team has collaboratively decided on pharmacologic therapy for the client. Which type of medication would the nurse expect to provide to treat the​ client's condition? -Antipsychotic -Anxiolytic -Antidepressant -Antispasmodic

-Antipsychotic

The nurse is providing care to a client who reads hidden meanings or threatening meanings in benign comments. Which treatment does the nurse anticipate for this​ client? -Anxiolytic therapy -Psychodynamic therapy ​-family-focused therapy ​-Anger-management therapy

-Anxiolytic therapy

Mary​ Cooper, a​ 45-year-old female​ client, has been diagnosed with anxiety. The nurse understands that collaborative treatment may be required to help treat​ Mary's anxiety. The nurse is preparing to provide Mary with education regarding the medication​ Mary's healthcare provider just prescribed. The nurse would expect to discuss which type of medication with​ Mary? -Antispasmodics -Antipsychotics -Anticholinergics -Anxiolytics

-Anxiolytics

The nurse is completing an assessment for a client who has manifestations of a personality disorder. Which assessment approach is most appropriate for this​ client? -Asking questions that allow the client to describe aspects about self -Asking questions about the Final Four game last evening -Asking questions that allow the client to describe aspects about the client​'s family -Asking questions that allow the nurse to speak more than the client

-Asking questions that allow the client to describe aspects about self

Takeisha is a​ 17-year-old African American female who came to the health care providers office with a complaint of amenorrhea for the past 4 months. She is accompanied by her​ mother, who tells the nurse that Takeisha is a straight A student who plays softball for her high school. Takeisha hopes to become a model for athletic clothes and participates in many local modeling events. She runs 5 miles before school each​day, and 3-4 times a week she stays after softball practice and runs another 5 miles. Takeisha is 58 and was last weighed 5 months ago at her annual​ physical, which was recorded as 120 lbs. She now weighs 25 lbs less. Takeisha quickly interjects that her schedule is too busy for her to eat balanced meals. She eats most of her meals away from​ home, and they consist primarily of energy bars and sports drinks. Her mother adds that she is a single mom and does not make many meals at home. Neither Takeisha nor her mother seems concerned at this time about the weight loss. They are more concerned about the amenorrhea. Takeisha states that she is not sexually active and has no time or interest in establishing relationships with boys. She is working very hard to get a​ full-time modeling job after she graduates. When the nurse asks Takeisha about her​appearance, Takeisha states that she feels and looks athletic rather than considering that she is rather thin compared with others girls on her team. When asked about her​ friends, Takeisha states that it is hard for her to make and keep friends because she does not have much time outside her sports interest and studying. Until about a year​ ago, Takeisha spent most of her free time with her mom. Takeisha tells you that her mom has a new​ boyfriend, and that she resents the time he spends with her mom that they used to spend together. He also teases her constantly that African American girls are too fat to be models. While taking Takeishas history you note which risk factors for anorexia​ nervosa? Select all that apply. -Athlete -Adolescent -Perfectionist -Female -African American

-Athlete -Adolescent -Perfectionist -Female

Which component is required in a nursing assessment of a client diagnosed with an eating​ disorder? Select all that apply. -Attitude toward food -Current medication list -Condition of the teeth -Cognitive functioning tests -Body mass index

-Attitude toward food -Current medication list -Condition of the teeth -Body mass index

The community health nurse is preparing a seminar on preventive methods to decrease risk factors for developing personality disorders. Which resource is appropriate for the nurse to include in the​ presentation? Select all that apply. -The Boys and Girls Club -Big Brothers Big Sisters Program -YMCA -The Nurse-Family Partnership Program -Incredible Years Program

-Big Brothers Big Sisters Program -The Nurse-Family Partnership Program -Incredible Years Program

The nurse is assessing a client who reports eating to the point of discomfort at least two times a week for the past year. The client denies use of​ laxatives, self-induced​ vomiting, ipecac​ syrup, or​ enemas, and feels unable to control the behavior. The client feels embarrassed and has stopped going out with friends. Which eating disorder should the nurse suspect this client​ has? -Anorexia nervosa ​-Binge-eating disorder -Bulimia nervosa -Purging

-Binge-eating disorder

​Hanna, a​ 48-year-old woman, has been admitted for treatment of anorexia nervosa following a heart arrhythmia and presyncopal episode. Which health care​ provider's order should cause the nurse to ask for​ clarification? -Blood glucose monitoring -Thyroid function tests -Electrocardiography -Urinalysis

-Blood glucose monitoring

A client is discussing her feelings regarding her eating disorder with the nurse. The client shares that when she looks in a​ mirror, she sees herself as "fat" even though her body mass index is 18. This statement is consistent with which thought​ pattern? -Body image distortion -Deception -Therapeutic relationship -Purging

-Body image distortion

You are preparing to perform your daily evaluation of Takeishas progress in meeting her goals as listed on the nursing care plan. Which nursing diagnoses will you​ evaluate? Select all that apply. -Client has a disturbed body image. -Client has chronic low​ self-esteem. -Client has deficient fluid volume. -Clients nutrition is less than body requirements. -Clients coping skills are ineffective.

-Client has a disturbed body image. -Client has chronic low​ self-esteem. -Clients nutrition is less than body requirements. -Clients coping skills are ineffective.

The nurse is evaluating a client who is showing behaviors of being​ dramatic, emotional, and erratic. Based on these assessment​ findings, which cluster of personality disorders will the nurse document for this​ client? -Cluster D -Cluster A -Cluster B -Cluster C

-Cluster B

Which form of intervention is the primary treatment used with clients who have feeding and eating​ disorders? -Pharmacologic therapy -Cognitive-behavioral therapy​ (CBT) ​-Schema-focused therapy -Dialectical behavioral therapy

-Cognitive-behavioral therapy​ (CBT)

A nurse is reviewing the medical record for a client who was admitted following a cardiac arrhythmia related to an eating disorder. Which of the abnormal clinical findings is common in clients with eating​ disorders? Select all that apply. -Concentrated urine -Electrolyte imbalance -Increased urine output -Dehydration -Hypotension

-Concentrated urine -Electrolyte imbalance -Dehydration -Hypotension

During group therapy one​ morning, Ann tells the group that she loves to date a lot of men and really enjoys it when they fight over her. She tells them different stories to get their attention and enjoys watching them get angry at each other just so she'll get the attention she deserves and wont be alone. You document which signs of unstable interpersonal​ relationships? Select all that apply.​ -Controlling and demanding behavior -Clinging and exploitive behavior -Intense empathy with everyone she is dating -Pitting individuals against each other -Multiple relationships to avoid being alone

-Controlling and demanding behavior -Clinging and exploitive behavior -Pitting individuals against each other -Multiple relationships to avoid being alone

Which specific independent interventions would the nurse provide to a client who is diagnosed with alteration of​ self? Select all that apply. -Creating a safe environment for the client to talk -Promoting adequate nutrition to the client -Helping the client identify strengths and weaknesses -Providing cognitive-behavioral therapy to the client -Providing pharmacologic therapy to the client

-Creating a safe environment for the client to talk -Promoting adequate nutrition to the client -Helping the client identify strengths and weaknesses

Which behavior that places the client at risk of injury is not usually associated with an eating​ disorder? -Inadequate caloric intake -Excessive exercise -Purging -Cutting

-Cutting

As part of her plan of​ care, you prepare to teach Ann about impulsive behaviors and how she can monitor and learn to control them. Which behaviors will you include in her teaching​ plan? Select all that apply. -Cutting her arms and other acts of​ self-injury -Extreme rage in response to unimportant events -Disregard for the consequences of her behavior -Indifference to others feelings -Unwillingness to take responsibility for her actions

-Cutting her arms and other acts of​ self-injury -Disregard for the consequences of her behavior -Indifference to others feelings -Unwillingness to take responsibility for her actions

The nurse is working with a team of healthcare professionals to care for a client with a personality disorder. The team has collaboratively decided on psychiatric therapy for the client. Which specific types of therapies are most commonly used to treat the​ client's condition? Select all that apply. -Dialectical behavioral therapy -Expressive therapy -Collaborative therapy -Cognitive-behavioral therapy​ (CBT) ​-Schema-focused therapy

-Dialectical behavioral therapy -Expressive therapy -Cognitive-behavioral therapy​ (CBT) ​-Schema-focused therapy

According to​ Freud's Psychosexual Theory of​ Development, what are the three primary elements of the human​ personality? Select all that apply. -Real self -Ideal self -Ego -Id -Superego

-Ego -Id -Superego

A​ 52-year-old woman is brought to the emergency department via ambulance after being found unconscious on the bathroom floor by her daughter. The daughter reports that her mother has been struggling with eating disorders for "as long as she can remember" and has been in and out of treatment programs for bulimia nervosa. Which test should the nurse expect the health care provider to​ order? Select all that apply. -Electrocardiography -Comprehensive metabolic panel​ (CMP) -Blood glucose monitoring -Urinalysis -CT scan

-Electrocardiography -Comprehensive metabolic panel​ (CMP) -Blood glucose monitoring -Urinalysis

Which statement should the nurse include in a presentation regarding eating​ disorders? Select all that apply. -Electrolyte imbalance is a common problem associated with eating disorders. -Eating disorders can cause malnutrition. -Excessive exercise can be associated with an eating disorder. -Diet pills and laxatives are not used by people with eating disorders. -Teenagers are the only age group with eating disorders.

-Electrolyte imbalance is a common problem associated with eating disorders. -Eating disorders can cause malnutrition. -Excessive exercise can be associated with an eating disorder.

Helping Ann learn to control her manipulative behavior requires strict limit setting. Which goals for limit setting should be included in her plan of​ care? Select all that apply. -Control the risk for suicide -Establish personal and professional boundaries -Prevent escalation of negative behavior -Decrease the risk of depression -Counteract resistance from the client

-Establish personal and professional boundaries -Prevent escalation of negative behavior -Counteract resistance from the client

The nurse encounters a client who has trust issues with others and is not being open to treatment. The client often sits in a corner away from everyone else in the room. Which nursing intervention is appropriate for this​ client? -Discharging the client from the hospital -Establishing a nurse-client relationship -Making the client sit with the rest of the group -Leaving the client in the corner of the room

-Establishing a nurse-client relationship

The nurse is preparing to perform a nursing assessment on a client diagnosed with a personality disorder. Which action by the nurse would ensure an effective​ assessment? -Establishing an authoritative environment -Asking​ detailed, personal questions -Asking questions related to family​ members' mental health -Establishing a therapeutic environment

-Establishing a therapeutic environment

The nurse is caring for an adolescent client who is diagnosed with a personality disorder. Which assessment finding supports this​ diagnosis? -Experiencing manic highs -Exhibiting narcissism -Feelings of anxiety -Hearing voices

-Exhibiting narcissism

Which critical clinical manifestation does Takeisha exhibit that supports a diagnosis of anorexia​ nervosa? -Extreme weight loss -Compulsive exercising -Serum electrolytes -Thought distortions

-Extreme weight loss

Which is a risk factor for developing a personality disorder​ (PD)? Select all that apply. -Family life -Genetics -Low socioeconomic status -Minimal physical activity -Childhood abuse

-Family life -Genetics -Low socioeconomic status -Childhood abuse

What are the risk factors for the development of mood​ disorders? Select all that apply. -Family member with depression -Childhood sexual abuse -Female gender -Male gender -Caucasian ethnicity

-Family member with depression -Childhood sexual abuse

You are preparing a teaching plan for Takeisha about her anorexia. You know you must build in areas to emphasize in repeat sessions during her hospital stay. Which are the key areas of teaching you will build into your​ plan? Select all that apply. -How to recognize situations and events that trigger anxiety. -Food is necessary in​ life, but moderation must be learned. -Feelings are normal and there is no need to fear them. -Expressing​ love, affection, and​ appreciation, verbally and​ physically, are important to recovery. -Avoid arguments about food and eating behaviors.

-Food is necessary in​ life, but moderation must be learned. -Feelings are normal and there is no need to fear them. -Expressing​ love, affection, and​ appreciation, verbally and​ physically, are important to recovery. -Avoid arguments about food and eating behaviors.

Which are types of psychotherapy used in the treatment of personality​ disorders? Select all that apply. -Group therapy ​-Schema-focused therapy -Cognitive-behavioral therapy -Dialectical behavioral therapy -Physical therapy

-Group therapy ​-Schema-focused therapy -Cognitive-behavioral therapy -Dialectical behavioral therapy

​Mary, a​ 23-year-old client, is seen for an annual​ OB/GYN check-up. The nurse is reviewing​ Mary's medical record prior to the health care​ provider's physical examination and notes that Mary has lost 50 pounds since her last visit.​ Mary's last recorded weight was 145​ pounds; she now weighs 95 pounds. While Mary was overweight for her height at the previous​ visit, she is now underweight. The nurse suspects that Mary may be anorexic. Which assessment finding would support this​ suspicion? -Stained teeth -Hypotension -Hypokalemia -Scars on fingers

-Hypotension

The nurse is reviewing laboratory results for a client diagnosed with anorexia nervosa. Which result is not consistent with the client​'s ​diagnosis? -Decreased serum potassium -Ketones present in the urine -Urine specific gravity of 1.030 -Increased level of ferritin

-Increased level of ferritin

What are important nursing actions when performing a nursing assessment of a client with a suspected alteration of​ self? Select all that apply. -Interview the client. -Assess the​ client's role mastery. -Assess the​ client's personal identity. -Establish a safe environment. -Establish a therapeutic relationship.

-Interview the client. -Establish a safe environment. -Establish a therapeutic relationship.

You are reviewing and revising your nursing care plan for Ann. Which interventions designed to control her manipulative behavior will you​ include? Select all that apply. -Involving her in assertiveness training to reduce the risk for aggressive behavior -Assigning one staff member as the primary resource person to consistently reduce opportunities for splitting the staff -Removing limits from the treatment plan on a scheduled basis -Setting limits that are realistic with enforceable consequences to control and reduce negative behavior -Modeling​ respect, honesty,​ openness, and assertive behavior to demonstrate expected and acceptable behavior

-Involving her in assertiveness training to reduce the risk for aggressive behavior -Assigning one staff member as the primary resource person to consistently reduce opportunities for splitting the staff -Setting limits that are realistic with enforceable consequences to control and reduce negative behavior -Modeling​ respect, honesty,​ openness, and assertive behavior to demonstrate expected and acceptable behavior

Ann tries to cut herself one night with a plastic knife. She tells you that she just had to cut myself. Theres no other way I can feel anything. Which would be the best​ response? -Thats a pretty misguided way to feel anything. -I guess you would feel something. It must​ hurt! -You seem to feel a lot because of the way youre always angry at everyone. -Lets talk about what led up to your cutting yourself.

-Lets talk about what led up to your cutting yourself.

During an interdisciplinary team​ meeting, Anns case is discussed and a therapeutic plan is formulated. Which strategies or approaches will the team include in the therapeutic​ plan? -Making sure team members are in constant communication with each other to ensure consistent client interactions. -Providing Ann with a daily schedule of activities. -Implementing strategies to promote sleep. -Allowing Ann to select preferred caregivers to accelerate personal growth.

-Making sure team members are in constant communication with each other to ensure consistent client interactions.

Takeisha continues her treatment at the adolescent treatment facility. She comes to you in tears one evening and begs not to go to dinner. Shes been eating and has gained five pounds over the last week. You have engaged in a personal​ self-assessment to gauge your own reactions to clients with anorexia. You know that you identify with clients with weight concerns because you are trying to control your own weight after the recent delivery of your first child. Your​ self-awareness helps you recognize that Takeishas request is a reflection of which type of behavior common to clients with​ anorexia? ​-Self-absorption -Pleading -Manipulation -Pleasing others

-Manipulation

The nurse is providing care to a client diagnosed with a personality disorder who often reports feelings of anxiety. The client would like to explore alternative forms of therapy. About which therapy that is known to be helpful in the treatment of personality disorders would the nurse educate the​ client? -FFT -SSRI therapy -Meditation therapy -DBT

-Meditation therapy

A client has come to the mental hospital. The nurse​'s assessment has shown clinical manifestations of perfectionism interfering with task completion and excessive devotion to work. Which diagnosis does the nurse anticipate based on the assessment​ findings? -Avoidance personality disorder -Dependent personality disorder -Histrionic personality disorder -Obsessive-compulsive personality disorder

-Obsessive-compulsive personality disorder

The nurse is providing care to a newly admitted client tentatively diagnosed with schizotypal personality disorder​ (Cluster A). Which assessment finding supports this client​'s ​diagnosis? -Paranoia -Panic -Impulsivity -Irritability

-Paranoia

Which components form​ self-concept? Select all that apply. -Global​ self-esteem -Personal identity ​-Self-awareness -Role performance -Body image

-Personal identity -Role performance -Body image

During an​ examination, a client admits that he cannot control his urge to eat paper. The nurse suspects the client is suffering from an eating or feeding disorder. Which specific disorder would the nurse​ consider? ​-Binge-eating disorder ​-Avoidant/restrictive food intake disorder -Pica -Nocturnal​ sleep-related eating disorder

-Pica

During the admitting​ assessment, you observed that Ann withdrew from her parents and kept her eyes averted. You document that there needs to be​ follow-up about which possible precursor to borderline personality​ disorder? -Possible childhood physical or sexual abuse -History of trouble with authority -Possible severe childhood illness -History of oppositional defiance

-Possible childhood physical or sexual abuse

After a thorough outpatient​ evaluation, Takeisha is admitted to an adolescent treatment center specializing in eating disorders. As you begin to develop a nursing care​ plan, you recognize that the plan must be holistic to take into account multiple etiological factors. Which of the multiple etiologies are reflected in Takeishas​ history? -Psychological and sociologic ​-biologic, sociologic, and psychological -Psychological and biologic -Biologic and sociologic

-Psychological and sociologic

A client presents to the urgent care clinic with complaints that "my heart feels like it is skipping beats." The client reports always feeling​ cold, and the body mass index is calculated at 18. What other clinical manifestation should the nurse watch for if the client is suspected of having anorexia​ nervosa? Select all that apply. -Rigidity and the need to control situations -Extreme perfectionism -Feelings of euphoria -Strenuous exercising -Obsession over body shape

-Rigidity and the need to control situations -Extreme perfectionism -Strenuous exercising -Obsession over body shape

The nurse is caring for a client who is a young mother and is putting herself through college by working a​ full-time job. The client seems anxious and​ fatigued, and the nurse suspects she is experiencing an alteration of self. Which specific element of​ self-concept would the nurse​ consider? -Role conflict -Personal identity conflict -Introspection conflict ​-Self-awareness conflict

-Role conflict

Which pharmacologic therapy is used for a client diagnosed with a personality disorder​ (PD)? -Anticholinergics ​-Beta-blockers -Selective serotonin reuptake inhibitors -Antihypertensives

-Selective serotonin reuptake inhibitors

The nurse is caring for a client who is attractive and athletic. The client reveals that he is very disappointed in his own academic abilities and feels embarrassed around his​ well-educated friends. Which specific element of​ self-concept would the nurse recognize as affecting the​ client? ​-Self-awareness -Global​ self-esteem -Public self -Specific​ self-esteem

-Specific​ self-esteem

Ann Callahan is a​ 28-year-old-female who is admitted to your unit with a diagnosis of borderline personality disorder. She presents with a history of alcohol​ abuse, marijuana ​use, and a recent suicide attempt by overdosing on her antidepressant. She has small cuts on her arms where she has used a knife to feel alive. Her parents tell you that she was feeling depressed because she recently got fired from her fourth job in two years as a receptionist. The latest job she had was at a local beauty salon where she worked with other women. Ann accused them of trying to steal her boyfriends and talking badly about her to all the customers just because she was prettier than any of them. As you observe her interactions with her parents in the interview​ room, you see that Ann withdraws when they begin to talk and keeps her eyes downcast and averted from her father. Based on Ann's health history and your​ observations, you document which signs and symptoms of borderline personality disorder​ (BPD)? Select all that apply.​ -Dissociation -Substance abuse -Impulsivity -Unstable relationships -Depression

-Substance abuse -Impulsivity -Unstable relationships

Ann has several scars on her arms from cutting herself. She tells you that it helps her to feel alive. You also note her prior overdose of antidepressants. You revise your nursing care plan to include which​ assessment? -Suicide risk assessment -Neurologic risk assessment -Manipulative behavior assessment -Medication adherence assessment

-Suicide risk assessment

Takeisha's mother is participating in a family education group in order to help prepare for Takeisha's discharge. Which key teaching points are important for Takeisha's mother to know and to teach other people who are important in Takeisha's​ life? Select all that apply. -Takeisha must want to make herself better and be willing to change her behaviors. -Takeisha will take positive steps forward and a few steps backward in her recovery. -Takeisha is learning to eat in moderation and should not be forced to eat. -Takeisha should be encouraged to participate in support groups to learn from others. -Takeisha must be watched closely for returning signs of binging and purging.

-Takeisha must want to make herself better and be willing to change her behaviors. -Takeisha will take positive steps forward and a few steps backward in her recovery. -Takeisha is learning to eat in moderation and should not be forced to eat. -Takeisha should be encouraged to participate in support groups to learn from others.

You are spending time with Takeisha after she sees the health care provider. Takeisha​ says, My doctor says I have to eat and gain​ weight, but I still have this fat little tummy. What is your best​ response? -Yes, you mustl-you are way too​ thin! -Its important you do what the doctor tells you. -Tell me what you are feeling right now. -What little​ tummy? I dont see any fat.

-Tell me what you are feeling right now.

The nurse is reviewing a questionnaire completed by an adolescent client. Which predisposing factor may increase the client​'s risk of an eating​ disorder? Select all that apply. -The client lists alprazolam​ (Xanax) on the home medication list. -The client reports a history of childhood abuse. -The client​'s mother has a history of bulimia nervosa. -The client lists "checkout clerk in a grocery store" as the occupation. -The client reports good family support and a healthy friendship network.

-The client lists alprazolam​ (Xanax) on the home medication list. -The client reports a history of childhood abuse. -The client​'s mother has a history of bulimia nervosa.

A nurse has admitted a​ 43-year-old woman whose anorexia nervosa is complicated by dehydration and a cardiac arrhythmia. Which is a positive outcome for this​ client? Select all that apply. -The client stated that she liked how she looked in the new dress. -The client had a​ 24-hour fluid intake of 600 mL. -The client remained free of injury. -The client attended therapy sessions as scheduled. -The client increased nutritional intake by​ 20%.

-The client stated that she liked how she looked in the new dress. -The client remained free of injury. -The client attended therapy sessions as scheduled. -The client increased nutritional intake by​ 20%.

The nurse and a client with an eating disorder have set up a behavioral contract to guide the client toward healthier eating patterns. Which goal should be incorporated in the​ contract? Select all that apply. -The client will attend and participate in therapy. -The client will not engage in purging behaviors. -The client will stop compulsive thinking about weight. -The client will maintain adequate caloric intake. -The client will limit exercise to 30 minutes per day.

-The client will attend and participate in therapy. -The client will not engage in purging behaviors. -The client will maintain adequate caloric intake. -The client will limit exercise to 30 minutes per day.

A client has attended and completed her inpatient therapy for bulimia nervosa. She has been making healthy choices in her daily​ meals, has not​ overeaten, and has not made herself vomit. She reports she is feeling in control of her weight. Which priority goal has the client​ achieved? -The client will remain free of injury. -The client will not demonstrate purging behaviors. -The client will not deny presyncopal episodes. -The client will maintain serum electrolytes within normal limits.

-The client will not demonstrate purging behaviors.

Although Takeisha's weight at 100 pounds is not yet life​ threatening, her resistance to participating in her care causes you concern. When you discuss this with​Takeisha, she tells you that she has never had time to eat well and her mother didn't cook often enough for her to know what was good or not good. She wants to control what she eats so she doesn't gain too much weight. You consult with the dietitian to plan a menu for Takeisha and include Takeisha in the planning. Which is the best rationale for including​ Takeisha? -This approach enlists Takeisha as an active participant in her treatment. -This approach reassures Takeisha that she still has all the control over her nutrition. -This approach conveys your acceptance of Takeisha and your confidence. -This approach plans for a slow introduction of food to Takeishas system.

-This approach enlists Takeisha as an active participant in her treatment.

A new staff nurse is caring for​ 22-year-old Sara, who has been diagnosed with an eating disorder. Implementing which nursing intervention indicates that the nurse requires additional​ education? -Allowing the client to eat her meals in private -Initiating a behavioral contract -Supervising the client in the clinical setting -Encouraging the client to participate in therapy sessions

Allowing the client to eat her meals in private

Which is included in the health history portion of the nursing assessment for a client diagnosed with a personality​ disorder? -Vital sign assessment -Focused system assessment -Assessment for symptoms of cutting -Assessment for history of drug or alcohol use

Assessment for history of drug or alcohol use

Courtney is a​ 30-year-old client who has been diagnosed with paranoid personality disorder. Which nursing intervention is the priority for Courtney based on her​ diagnosis? -Building and maintaining trust with Courtney to promote a sense of safety -Determining specific​ needs, strengths, and functional capabilities -Measuring​ Courtney's goals and specific outcomes that are able to be evaluated at the conclusion of the nursing process -Interviewing Courtney to identify her​ behaviors, beliefs, and thought processes

Building and maintaining trust with Courtney to promote a sense of safety

The nurse is conducting a group therapy session for the clients diagnosed with borderline personality disorder. Which additional therapy may be beneficial for the nurse to facilitate during the group therapy​ session? -Wound therapy -Hydrotherapy -Expressive therapy -Massage therapy

Expressive therapy

Timothy is an​ 18-year-old client who is being interviewed by the mental health nurse after being arrested and committed to a​ 72-hour hold. The client is diagnosed with antisocial personality disorder. Which data collected during the nursing assessment support this​ client's diagnosis? -Feelings of emptiness -Poorly developed interpersonal skills -Feelings of irritability -Suicidal ideations

Feelings of irritability

A nursing administrator is creating a form to be used in the focused assessment of a client​'s nutritional status. Which component is not appropriate to include on the​ form? ​-Height, weight, and body mass index​ (BMI) -Diagnostic test results -Client interview -Interview of the client​'s family

Interview of the client​'s family

The nurse is providing care to a client diagnosed with a personality disorder. Which behaviors would categorize this client with​ antagonism? Select all that apply. Exhibiting​ risk-taking behaviors Lying to parents Avoiding intimacy Feelings of grandiosity Being manipulative with friends

Lying to parents Feelings of grandiosity Being manipulative with friends

The nurse is caring for a client who is suspicious of all activities that occur during psychotherapy sessions because of to the paranoia associated with the diagnosed personality disorder. Which intervention is the priority for this​ client? -Suggesting group interactivity -Sharing personal information -Identifying manipulative tactics -Maintaining confidentiality

Maintaining confidentiality

The nurse is caring for a client who is suffering from an eating or feeding​ disorder, but the nurse is having difficulty establishing a therapeutic relationship with the client. Which specific factor may be making it difficult for the nurse to establish this​ relationship? -Recovery rates are poor for clients with eating disorders. -Clients may not be capable of​ self-awareness. -Creating a safe environment for the client is exceptionally difficult. -Providing nutrition counseling may be perceived as an attempt at control.

Providing nutrition counseling may be perceived as an attempt at control.

Which intervention is not specific to the nursing care provided to a client diagnosed with a personality​ disorder? -Maintaining confidentiality -Establishing a behavioral contract -Removing harmful items from the client environment -Recommending a​ disease-specific diet

Recommending a​ disease-specific diet

Which evaluation statement indicates successful treatment for a client diagnosed with a personality​ disorder? -The client continues to exhibit manifestations of anxiety. -The client remains free from injury. -The client remains free from airway disturbances. -The client refuses to adhere to rules and guidelines.

The client remains free from injury.

Which is an example of the appropriate goal statement for a client diagnosed with a personality​ disorder? -The client​'s blood pressure will be normal before discharge. -The client will remain free from injury. -The client will refrain from violent behaviors. -The client will verbalize emotions to staff. -The client will actively participate in​ one-on-one and/or group therapy sessions.

The client will verbalize emotions to staff.

During an​ examination, the nurse suspects that the client may be in the beginning stages of an eating or feeding alteration. Which question would the nurse ask the client during the personal identity portion of the psychosocial​ assessment? ​-"In one or two​ words, how do you feel about your​ body?" ​-"How do you describe​ yourself?" ​-"What do you think when you look at your body in a​ mirror?" -​"How important is physical appearance to​ you?"

​-"How do you describe​ yourself?"

A client confesses that she secretly eats large amounts of food and then feels guilty about it afterward. Which response would the nurse give to this​ client? ​-"Do you regularly eat nonfood items and regurgitate​ them?" ​-"You might have Prader-Willi ​syndrome, which is a chromosomal​ disorder." ​-"It sounds as though you may be suffering from what is called​ binge-eating disorder." ​-"Have you noticed any insomnia or weight loss associated with your​ behavior?"

​-"It sounds as though you may be suffering from what is called​ binge-eating disorder."

The nurse is caring for​ 16-year-old Lucia​ Morales, who is slightly overweight. Lucia tells the nurse that she has not been swimming this summer because she does not want to go to a public place in a swimsuit. Which response would the nurse give to​ Lucia? -​"The mental picture you have of your physical self is completely​ inaccurate, and I am recommending​ cognitive-behavioral therapy." ​-"Society promotes unrealistic images of the ideal​ body, and you should embrace the positive aspects of​ yourself." ​-"You are​ obese, and you should consult with a nutritionist and personal​ trainer." ​-"Your perceived body image is​ accurate, but you should focus more on your health and not on your actual​ weight."

​-"Society promotes unrealistic images of the ideal​ body, and you should embrace the positive aspects of​ yourself."

The nurse is caring for​ 15-year-old Taylor Moore at an outpatient pediatric office.​ Taylor's father is concerned that his daughter is developing an eating disorder.​ Taylor's father asks the​ nurse, "Are there any laboratory tests that would diagnose an eating disorder in​ Taylor?" Which response would the nurse give to​ Taylor's father? -​"A urinalysis test can tell us if Taylor is developing an eating​ disorder." ​-"We can run a complete blood count test to see if Taylor has an eating​ disorder." ​-"A liver-function test can determine whether Taylor has an eating​ disorder." ​-"Unfortunately, there are no laboratory tests to diagnose eating​ disorders."

​-"Unfortunately, there are no laboratory tests to diagnose eating​ disorders."

A client reveals that she feels guilty about her thoughts of leaving her husband and that it is causing her a lot of emotional distress. If applying​ Freud's psychoanalytic theory to the​ issue, which response would the nurse give to the​ client? -​"You would benefit from​ psychoanalysis, and I am referring you to a​ specialist." ​-"While those thoughts may seem​ disturbing, it means that you have reached a level of​ self-awareness." ​-"You may feel guilty because your desires are in conflict with what​ everyone, including​ yourself, expects from​ you." -​"You may be feeling guilty because of an interrole conflict that is affecting your​ self-concept."

​-"You may feel guilty because your desires are in conflict with what​ everyone, including​ yourself, expects from​ you."

Ann comes up to you after the team meeting and​ says, Youre so helpful. I know you can help me get a pass to go home this weekend. Which response to her comment is the most​appropriate? ​-Ann, that is so​ sweet! Ill talk to the team and do what I can to get you a pass to go home. I know its important. ​-Ann, when you compliment me to get what you​ need, you just make me angry and I dont want to help you. ​-Ann, when you compliment people to get something from​ them, they will quickly learn not to trust anything you say. ​-Ann, thats​ nice, but compliments will get you nowhere with me. Go try another nurse.

​-Ann, when you compliment people to get something from​ them, they will quickly learn not to trust anything you say.

The nurse is performing a psychosocial assessment of a client. Which specific behavioral elements would the nurse​ observe? Select all that apply. ​-Client's spiritual affiliations and practices ​-Client's current roles and role conflicts ​-Client's ability to follow a conversation ​-Client's verbal expression of emotion ​-Client's nonverbal cues

​-Client's ability to follow a conversation ​-Client's verbal expression of emotion ​-Client's nonverbal cues

​Nina, a​ 32-year-old woman, presents to the clinic with a history of bulimia nervosa.​ Nina's body mass index is 18. Which finding during the physical examination represents a positive outcome for this​ client? -Deteriorating enamel on the​ client's teeth -Bruises ​-Strong, shiny hair -Poor skin turgor

​Strong, shiny hair