Care Management 1 Exam 1

Which situation represents the id component of human personality as mentioned by Freud? Select all that apply. One, some, or all responses may be correct. A) A client experiencing pain takes pain medication prescribed for a family member. B) A client feels nauseous and so leaves work to go to a health care facility. C) A client wishes to go home and slips out of the health care facility quietly without anyone noticing. D) A client feeling hungry notices a food tray at the next bed but does not grab the food because a nurse is watching. E) A client feeling thirsty waits for the nurse to bring the water instead of taking it from the next client because of knowing this is wrong.

A) A client experiencing pain takes pain medication prescribed for a family member. B) A client feels nauseous and so leaves work to go to a health care facility. C) A client wishes to go home and slips out of the health care facility quietly without anyone noticing.

Which example represents the ego component of human personality, according to Freud? Select all that apply. One, some, or all responses may be correct. A) A client wants to eat junk food but does not order it because the dietitian is keeping track of the client's weight. B) A client notes the nurse is late in bringing their food tray, so the client steals food from the cafeteria. C) A client feels the next client received a better pillow but refrains from taking it because that behavior is wrong. D) A client with insomnia wants to take an extra sleeping pill but refrains from doing so because the caregivers are present. E) A client is attracted to the nurse in charge but does not make any advances because there are other clients in the same ward.

A) A client wants to eat junk food but does not order it because the dietitian is keeping track of the client's weight. D) A client with insomnia wants to take an extra sleeping pill but refrains from doing so because the caregivers are present. E) A client is attracted to the nurse in charge but does not make any advances because there are other clients in the same ward.

Which situation represents the superego in a client, per Freud? Select all that apply. One, some, or all responses may be correct. A) Controlling the urge to eat candy because he or she knows it will affect blood sugar levels B) Having a craving for fruit but not stealing it from the next client because that client needs it more C) Urinating beside the bed instead of waiting for the nurse to assist him or her D) Experiencing a stomachache but refraining from stealing medications from a friend because it is illegal E) Feeling the urge to run away from the hospital but refraining from doing so because the security guard is watching

A) Controlling the urge to eat candy because he or she knows it will affect blood sugar levels B) Having a craving for fruit but not stealing it from the next client because that client needs it more D) Experiencing a stomachache but refraining from stealing medications from a friend because it is illegal

Which nursing actions best promote communication when obtaining a nursing history? Select all that apply. One, some, or all responses may be correct. A) Establishing eye contact B) Paraphrasing the client's message C) Asking "Why" and "how" questions D) Using broad, open-ended statements E) Reassuring the client that there is no cause for alarm F) Asking questions that can be answered with a "yes" or "no"

A) Establishing eye contact B) Paraphrasing the client's message D) Using broad, open-ended statements

Which behavior is expected for a child with attention-deficit/hyperactivity disorder (ADHD) ? Select all that apply. One, some, or all responses may be correct. A) Impulsiveness B) Excessive talking C) Spitefulness and vindictiveness D) Deliberate annoyance of others E) Playing video games for hours on end F) Failure to follow through or finish tasks

A) Impulsiveness B) Excessive talking E) Playing video games for hours on end F) Failure to follow through or finish tasks

Which priority action will the nurse implement when caring for a client diagnosed with schizophrenia who is exhibiting signs of impaired judgment, paranoia, and agitation? A) Protecting other clients B) Talking to the client in a calm manner C) Giving antipsychotic medication D) Placing the client in seclusion

A) Protecting other clients

The nurse is caring for a child who has attention-deficit/hyperactivity disorder (ADHD). Which change in the child's classroom will be beneficial? Select all that apply. One, some, or all responses may be correct. A) Providing breaks frequently at regular intervals B) Writing instructions on the blackboard after verbalization C) Increasing the number of classroom assignments and homework D) Improving the writing skills of the child compared with computer skills E) Scheduling academic subjects for times when the child is under the effect of medication

A) Providing breaks frequently at regular intervals B) Writing instructions on the blackboard after verbalization E) Scheduling academic subjects for times when the child is under the effect of medication

Which rights do clients have when they are admitted to an inpatient psychiatric facility? Select all that apply. One, some, or all responses may be correct. A) Receiving personal mail B) Refusing treatment C) Viewing written treatment plans D) Selecting health team members E) Being in the least restrictive environment F) Having freedom from excessive or unnecessary medication

A) Receiving personal mail B) Refusing treatment C) Viewing written treatment plans E) Being in the least restrictive environment F) Having freedom from excessive or unnecessary medication

School-age children who have conduct disorder, childhood-onset type, are at risk for progressing to which disorder during adolescence? A) Oppositional defiant B) Antisocial personality C) Pervasive developmental D) Attention -deficit/hyperactivity

B) Antisocial personality

Which signs and symptoms would the nurse observe in a client experiencing alcohol withdrawal? Select all that apply. One, some, or all responses may be correct. A) Fatigue B) Anxiety C) Runny nose D) Diaphoresis E) Psychomotor agitation

B) Anxiety D) Diaphoresis E) Psychomotor agitation

Which process would the nurse consider when formulating a response to a client with acute kidney injury who states "Why am I experiencing twitching and tingling of my fingers and toes?" A) Acidosis B) Calcium depletion C) Potassium retention D) Sodium chloride depletion

B) Calcium depletion

The nurse is administering intravenous (IV) fluids to a dehydrated infant. Which intervention is most important at this time? A) Calculating the total caloric intake B) Continuing the prescribed flow rate C) Making hourly temperature assessments D) Maintaining the fluid at body temperature

B) Continuing the prescribed flow rate

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? A) Rapid, thready pulse B) Distended jugular veins C) Elevated hematocrit level D) Increased serum sodium level

B) Distended jugular veins

To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor? A) Skin condition B) Fluid and electrolyte balance C) Food intake D) Fluid intake and output

B) Fluid and electrolyte balance

During a routine prenatal visit, a client tells the nurse that they often gets muscle weakness and leg cramps. Which condition would the nurse suspect, and which suggestion is made to correct the problem? A) Hypercalcemia; avoid eating hard cheeses B) Hypocalcemia; increase milk intake C) Hyperkalemia; consult the health care provider D) Hypokalemia; increase intake of green leafy vegetables

B) Hypocalcemia; increase milk intake

Upon completing a post-operative assessment, which finding would indicate to the nurse that the client may be experiencing a pulmonary embolus? Select all that apply. One, some, or all responses may be correct. A) Flushed face B) Increased temperature C) Severe abdominal pain D) Decreased oxygen saturation level E) Sudden onset of shortness of breath

B) Increased temperature D) Decreased oxygen saturation level E) Sudden onset of shortness of breath

Which initial action would the nurse take for a client admitted to an alcohol rehabilitation center who on the fourth day after admission has a strong odor of alcohol on breath? A) Ask where the client got the alcohol. B) Locate the alcoholic substance. C) Convey the staff's disappointment in this behavior. D) Document the client's drinking.

B) Locate the alcoholic substance.

At which point would the nurse start to discuss terminating the nurse-client relationship with a client? A) Working phase, when the client initiates it B) Orientation phase, when a contract is established C) Working phase, when the client shows some progress D) Termination phase, when discharge plans are being made

B) Orientation phase, when a contract is established

Which factor is a likely cause of hyponatremia? Select all that apply. One, some, or all responses may be correct. A) Diabetes insipidus B) Profuse diaphoresis C) Excess sodium intake D) Removal of the parathyroid glands E) Rapid intravenous (IV) infusion of 5% dextrose in water (D‚5W)

B) Profuse diaphoresis E) Rapid intravenous (IV) infusion of 5% dextrose in water (D‚5W)

Which clinical finding assessed in a client with the diagnosis of paranoid schizophrenia increases the risk for harm to self or others? Select all that apply. One, some, or all responses may be correct. A) Aloofness B) Prominent delusions C) Anxiety D) Stilted interactions E) Command hallucinations

B) Prominent delusions E) Command hallucinations

A client is emotionally immobilized since her husband requested a divorce and moved out of their home. Which assessment would be performed first? A) What factors contributed to his decision B) What the divorce means to the client C) Whether she is receptive to suggestions D) How she plans to support herself financially

B) What the divorce means to the client

A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? A) Sodium B) calcium C) Potassium D) Phosphorus

B) calcium

Which action would the nurse take first when managing interpersonal relationships with a client who has schizophrenia? A) Allow the client to be alone with quiet activities. B) Insist that the client join group meetings and activities with other clients. C) Establish a one-on-one relationship and then bring the client into group activities. D) Encourage dependence by the client initially, but set limits on the extent of this behavior.

C) Establish a one-on-one relationship and then bring the client into group activities.

A client with a history of alcohol abuse was admitted 2 days ago whose pulse rate and blood pressure have gradually increased and now has a low-grade fever. Place the following nursing interventions in the appropriate order to best minimize the client's risk for injury. A) Attempt to determine when the client last consumed alcohol B) Notify the primary healthcare provider of the findings C) Initiate seizure precautions D) Turn off the client's television and dim the room lights

C) Initiate seizure precautions D) Turn off the client's television and dim the room lights A) Attempt to determine when the client last consumed alcohol B) Notify the primary healthcare provider of the findings

Which intervention would the nurse include in the initial plan of care for a client with the long-standing obsessive-compulsive behavior of hand washing? A) Determine the purpose of the ritualistic behavior. B) Limit the time allowed for the ritualistic behavior. C) Suggest a symptom-substitution technique. D) Develop a routine schedule of activities.

D) Develop a routine schedule of activities.

Which nursing interventions are best for a client who states, "I get down on myself when I make a mistake." in a cognitive therapy approach? Select all that apply. One, some, or all responses may be correct. A) Teaching the client relaxation exercises to diminish stress B) Exploring with the client past experiences that have caused distress C) Providing the client with mastery experiences designed to boost self-esteem D) Encouraging the client to replace these negative thoughts with positive thoughts E) Helping the client modify the belief that anything less than perfection is unacceptable

D) Encouraging the client to replace these negative thoughts with positive thoughts E) Helping the client modify the belief that anything less than perfection is unacceptable

Which approach by the primary nurse for a hospitalized adolescent with conduct disorder would cause the nurse manager to intervene? A) Discussing unit rules B) Giving the client choices C) Explaining the consequences of not following unit regulations D) Encouraging the verbalization of negative feelings toward others

D) Encouraging the verbalization of negative feelings toward others

Which overall outcome would the school nurse formulate for a 6-year-old client with attention-deficit/hyperactivity disorder (ADHD)? A) Developing language skills B) Avoiding regressive behavior C) Attending regular classes in school D) Enhancing self-image as a worthy person

D) Enhancing self-image as a worthy person

Which long-term outcome would the nurse use for a child who has conduct disorder? A) Avoids verbally aggressive behavior for 4 months B) Verbalizes 10 alternative methods to address anger C) Is sent to the principal's office 5 times in 5 weeks D) Has no physically aggressive episodes for 3 months

D) Has no physically aggressive episodes for 3 months

Which intervention is the most important for a client who is diagnosed with bulimia nervosa? A) Watch for pilfering and hoarding of food. B) Encourage eating meals in the public dining area. C) Assess for mood swings after eating. D) Observe for amount consumed and purging.

D) Observe for amount consumed and purging.

Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEg of potassium be prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? A) Prevent constipation B) Prevent dehydration C) Prevent vomiting D) Prevent electrolyte imbalance

D) Prevent electrolyte imbalance

A client with schizophrenia is apathetic and exhibits an inappropriate affect. Which behavior is the client likely to exhibit? A)Logical deductions B) Suicidal preoccupation C)Absence of self-criticism D) Response to internal stimulation

D) Response to internal stimulation

Which topic would be most important for the nurse to address at a group session for 3 chronically ill clients who have the diagnosis of schizophrenia? A) Relaxation techniques B) Rational behavior therapy C) Assertiveness in relationships D) Social skills in group settings

D) Social skills in group settings

Which conclusion would the nurse make about a client who confides, "I've been thinking about suicide lately"? A) This statement is intended to frighten the nurse. B) The client wants attention from the staff. C) This statement indicates a feeling of safety with the nurse. D) The client is seeking protection from the impulses/thoughts.

D) The client is seeking protection from the impulses/thoughts.

Which response would the nurse make to the overstressed parent of a child with a tentative diagnosis of attention-deficit/hyperactivity disorder (ADHD) who insists on medication for the child? A) "It must be frustrating to deal with your child's behavior." B) "Have you considered any alternatives to using medication?" C) "Perhaps you're looking for an easy solution to the problem." D) "Let me teach you about the side effects of medications used for ADHD."

A) "It must be frustrating to deal with your child's behavior."

When a client is admitted with fluid overload would the triage nurse prioritize as requiring immediate care based on age and condition? A) 88 - Bounding pulse rate B) 12 - pale skin with pitting edema C) 21 - severe headache D) 36 - increased gastrointestinal motility

A) 88 - Bounding pulse rate

Which behavior by the client exhibits denial after a recent diagnosis? A) Attempts to minimize the illness B) Lacks an emotional response to the illness C) Refuses to discuss the condition with the client's spouse D) Expresses displeasure with the prescribed activity program

A) Attempts to minimize the illness

Which signs and symptoms would the nurse observe in clients with anorexia nervosa? Select all that apply. One, some, or all responses may be correct. A) Cachexia B) Purging C) Diarrhea D) Hypertension E) Lanugo

A) Cachexia B) Purging E) Lanugo

Which action would the nurse take for a client diagnosed with schizophrenia who is paranoid, delusional, withdrawn, and negativistic? A) Invite the client to play a game of cards with the nurse. B) Explain to the client the benefits of joining a group activity. C) Encourage the client to become involved in group activities. D) Mention to the client that the psychiatrist has prescribed increased activity.

A) Invite the client to play a game of cards with the nurse.

While assessing an older adult client before noon, the nurse smells alcohol on the client's breath. Which additional signs and symptoms would the nurse then monitor for? Select all that apply. One, some, or all responses may be correct. A) Irritability B) Poor hygiene C) Family conflict D) Good nutritional habits E) Excessive mood swings F) Strong cognitive skills

A) Irritability B) Poor hygiene C) Family conflict E) Excessive mood swings

When a client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? A) Complete a head-to-toe assessment. B) Start infusion of normal saline 500 mL. C) Ask the client about current medications. D) Obtain blood samples for laboratory testing.

B) Start infusion of normal saline 500 mL.

Which goal is applicable to adolescents with conduct disorder? A) Increased impulse control and ability to focus B) Identification of two positive personal attributes C) Demonstration of respect for the rights of others D) Age-appropriate play activities with at least one peer

C) Demonstration of respect for the rights of others

Which characteristic would the nurse observe in a client diagnosed with antisocial personality disorder? A) Suffers from extreme anxiety B) Rapidly learns by experience if punished C) Usually is unable to postpone gratification D) Has a great sense of responsibility toward others

C) Usually is unable to postpone gratification

Which behavior is consistent with a problem involving trust versus mistrust according to Erikson's stages of psychosocial development? A) Woman in an abusive relationship is unwilling to leave the abuser B) Man with paranoid schizophrenia demands placement in a private room C) Woman whose parents were chronic alcoholics has problems making friends D)Man with borderline personality disorder is caught stealing from other clients

C) Woman whose parents were chronic alcoholics has problems making friends

Which intravenous fluid is a hypertonic solution? A) Ringer solution B) 5% dextrose in water C) Lactated Ringer solution D) 5% dextrose in normal saline

D) 5% dextrose in normal saline

Which response would the nurse use when a client is observed hiding a bottle of whiskey in the back of a drawer? A) Wait and try to catch the client drinking the alcohol. B) Confiscate the alcohol when the client is not looking. C) Wait for the client to bring up the subject of drinking. D) Ask the client how much alcohol they consume in a week.

D) Ask the client how much alcohol they consume in a week.

Which defense mechanism is a client with diabetes mellitus using when they discuss in detail the diabetic metabolic process while eating a piece of chocolate cake? A) Projection B) Dissociation C) Displacement D) Intellectualization

D) Intellectualization

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? A) Slow heart rate B) Cool skin temperature C) Bounding radial pulses D) Increased urine output

B) Cool skin temperature

Which outcome would the nurse add to the plan of care for a client diagnosed with anorexia nervosa? A) Eat every meal for a week. B) Gain 1 1b (0.5 kg) of weight a week. C) Attend group therapy every day. D) Talk about food for 1 hour a day.

B) Gain 1 1b (0.5 kg) of weight a week.

Which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? Select all that apply. One, some, or all responses may be correct. A) Anorexia B) Constipation C) Muscle weakness D) Irregular heart rhythm E) Hyperactive bowel tones

C) Muscle weakness D) Irregular heart rhythm E) Hyperactive bowel tones

Which concern is most important after the initial crisis issues have been addressed? A) Nature of the precipitating factor B) Effect of the situation on significant others C) Client's ability to cope with successive crises D) Client's potential to perform activities of daily living

D) Client's potential to perform activities of daily living

Which symptoms are classified as negative symptoms for a client diagnosed with schizophrenia? Select all that apply. One, some, or all responses may be correct. A) Lack of energy B) Anhedonia C) Illogical speech D) Ideas of reference E) Agitated behavior

A) Lack of energy B) Anhedonia

Which personality traits are exhibited in a client who has a diagnosis of borderline personality disorder? Select all that apply. One, some, or all responses may be correct. A) Engaging B) Indecisive C) Withdrawn D) Manipulative E) Perfectionistic

A) Engaging D) Manipulative

Which behaviors would the nurse expect the client to do during the working phase of a therapeutic relationship according to Peplau's model of the nurse-client relationship? Select all that apply. One, some, or all responses may be correct. A) Initiate topics of discussion. B) Focus the conversation on the nurse. C) Repress emotionally charged material. D) Accept limits on unacceptable behavior. E) Express emotions related to transference.

A) Initiate topics of discussion. D) Accept limits on unacceptable behavior. E) Express emotions related to transference.

Which nursing intervention would be taken when the mother of an adolescent reports that her child does not eat properly, performs strenuous physical exercise, and is very introverted? Select all that apply. One, some, or all responses may be correct. A) Monitoring the adolescent's fluid and electrolyte status B) Checking for evidence of self-induced vomiting C) Monitoring the adolescent for disturbances in family interactions D) Counseling the adolescent about good personal hygiene and sanitation E) Developing a mutually agreeable targeted daily caloric intake goal

A) Monitoring the adolescent's fluid and electrolyte status B) Checking for evidence of self-induced vomiting C) Monitoring the adolescent for disturbances in family interactions E) Developing a mutually agreeable targeted daily caloric intake goal

Which action will the urgent care clinic nurse anticipate taking for a 24-year-old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure 102/56 mm Hg? A) Offer oral fluids at frequent intervals. B) Give fluid boluses through a nasogastric tube. C) Administer intravenous antiemetic medications. D) Insert a peripheral intravenous line for fluid infusion.

A) Offer oral fluids at frequent intervals.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention? A) Sitting quietly with the client B) Telling the client that crying is not helpful C) Suggesting that the client play a board game D) Recommending how the client can change this situation

A) Sitting quietly with the client

Which clinical indicator would the nurse expect when an intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. A) Heat B) Pallor C) Edema D) Decreased flow rate E) Increased blood pressure

B) Pallor C) Edema E) Increased blood pressure

Which defense mechanism is most commonly used by clients who are diagnosed with schizophrenia, undifferentiated type? A) Projection B) Repression C) Regression D) Conversion

C) Regression

A client with recently diagnosed diabetes states, "I feel bad. My spouse and I do not get along. It seems as though my spouse doesn't care about my diabetes." Which response by the nurse is appropriate? A) "You don't get along with your spouse." B) ''I'm sorry. What can I do to make you feel better?" C) "It may be temporary because your spouse also needs time to adjust. D) "You sound unhappy. Have you tried to talk to your spouse?"

D) "You sound unhappy. Have you tried to talk to your spouse?"

Which action would the nurse take for an adolescent client with anorexia nervosa? A) Reward weight gain by increasing privileges. B) Discuss the importance of eating a balanced diet. C) Encourage the client to include high-calorie foods in the diet. D) Suggest family therapy to focus on the client's behavior.

A) Reward weight gain by increasing privileges.

Which intervention would the nurse implement for a disturbed, acting-out client in the fetal position? A) Sitting down beside the client and saying, "I'm here to spend time with you!' B) Going to the client and saying, "I'll be waiting for you by the chairs, so please get up and join me." C) Tapping the client gently on the shoulder to get the client's attention and then staying with the client D) Leaving the client alone because the behavior demonstrates that the client is too regressed to benefit from verbal communication

A) Sitting down beside the client and saying, "I'm here to spend time with you!'

Which possible complication would a nurse monitor for when a client develops a venous thrombosis in the left calf? A) Embolic stroke B) Pulmonary embolism C) Myocardial infarction D) Ischemia of the left foot

B) Pulmonary embolism

Which defense mechanism is being used by a client who has amnesia after an automobile collision that caused fatalities and a subsequent arrest for speeding? A) Projection B) Repression C) Suppression D) Rationalization

B) Repression

Which action would the nurse take to assist a client diagnosed with schizophrenia who moves to the counter to choose food but is unable to decide what to do next? A) Provide nonverbal communication. B) Speak in simple declarative statements. C) Ask basic questions requiring simple choices. D) Reward the client for each of the food items chosen.

B) Speak in simple declarative statements.

Which class of medication would the nurse anticipate preparing to administer to a client with alcohol dependence admitted to a detoxification unit? A) Opiate B) Antipsychotic C) Antidepressant D) Benzodiazepine

D) Benzodiazepine

Which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to self? A) Focusing B) Clarifying C) Paraphrasing D) Summarizing

A) Focusing

Which nursing intervention would be essential for a client diagnosed with antisocial personality disorder who is admitted to the mental health hospital? A) Encouraging interactions with others B) Presenting a united, consistent staff approach C) Assuming a nurturing, forgiving tone in disputes D) Using seclusion when manipulative behaviors are exhibited

B) Presenting a united, consistent staff approach

Which intervention is the priority nursing care for a client in the coronary care unit who develops "viselike" chest pain radiating to the neck with a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis who is prescribed morphine sulfate 4 mg intravenous (IV) push stat and cardiac monitoring? A) Relief of pain B) Client teaching C) Cardiac monitoring D) Maintenance of bed rest

A) Relief of pain

For which behavior would the nurse incur liability in handling an inpatient psychiatric client who is laughing loudly and making inappropriate comments to other clients and staff? A) Reporting the client's behavior to the treatment team B) Checking the client's prescriptions for an as-needed medication to help calm the client C) Placing the client in seclusion only until the client stops verbally attacking clients and staff D) Bringing the client to a quiet area and encouraging a discussion of thoughts and behavior

C) Placing the client in seclusion only until the client stops verbally attacking clients and staff

A hostile client with the diagnosis of schizophrenia, says, "The voices are saying that they are going to poison me because I'm bad." Which type of schizophrenic behavior is the client displaying? A) Residual B) Paranoid C) Catatonic D) Disorganized

B) Paranoid

For an older adult client with dementia who developed dehydration as a result of vomiting and diarrhea, which assessment information best reflects the client's fluid balance? A) Skin turgor B) Intake and output results C) Client's report about fluid intake D) Blood lab results

D) Blood lab results

Which problem is most likely to underlie angry or hostile behavior for a client with the diagnosis of borderline personality disorder? A) Low self-esteem B) Inability to test reality C) Reaction to command hallucination D) Ineffective verbal communication

A) Low self-esteem

Which initial action should the nurse take for a client with schizophrenia who sits rocking in a corner for long periods and responds to voices with words that the staff cannot understand? A) Include the client in a discussion group on the unit. B) Encourage the client to talk to other clients during the day. C) Allow the client to be alone while observing from a distance. D) Arrange the client's day to allow for short periods to be spent with the nurse.

D) Arrange the client's day to allow for short periods to be spent with the nurse.

Place the following actions in order for a client experiencing high anxiety: A) Provide firm but kind directions B) Encourage deep breathing and relaxation techniques C) Place the client in restraints if deemed dangerous D) Attempt to identify the source of anxiety.

D) Attempt to identify the source of anxiety. B) Encourage deep breathing and relaxation techniques A) Provide firm but kind directions C) Place the client in restraints if deemed dangerous

Which statement by the nurse accurately describes the DSM-5 criteria for conduct disorder? Select all that apply. One, some, or all responses may be correct. A) "The client often initiates fights." B) "Others' basic rights are violated." C) "Three of 15 criteria must be present." D) "One criterion must be present in the past 6 months." E) "The behavior has caused the child to be suspended from school." F) "In adolescent onset, there are no symptoms before 10 years of age."

A) "The client often initiates fights." B) "Others' basic rights are violated." C) "Three of 15 criteria must be present." D) "One criterion must be present in the past 6 months." E) "The behavior has caused the child to be suspended from school." F) "In adolescent onset, there are no symptoms before 10 years of age."

Which initial statement would the nurse say to a client with borderline personality disorder who is badgering clients in the day room? A) "You must leave people alone; this behavior is unacceptable." B) "There will be consequences if you do not stop annoying people." C) "Tell me how you feel when you are exerting control over other people." D) "I'm surprised that you're acting this way; you seemed to have improved lately."

A) "You must leave people alone; this behavior is unacceptable."

Which nursing action would be appropriate when the client with alcohol withdrawal delirium begins experiencing hallucinations? A) Withholding intervention, because the client may be having vivid dreams B) Asking the client to describe the hallucinations and explaining that they are not real C) Administering the prescribed medication to the client to subdue the agitated behavior D) Pretending to visualize the imaginary things the client is describing to foster acceptance

C) Administering the prescribed medication to the client to subdue the agitated behavior

Which symptom would the nurse monitor for when caring for a client who has hyponatremia? A) Increased urine output B) Deep rapid respirations C) Change in level of consciousness D) Distended neck veins

C) Change in level of consciousness

During the termination phase of a therapeutic relationship, a client misses a series of appointments without any explanation. Which action would the nurse take? A) Terminate the relationship immediately. B) Explore personal feelings with the supervisor. C) Contact the client to encourage another session. D) Plan to attend the remaining designated meetings.

C) Contact the client to encourage another session.

Which response would the nurse give to a client with a possible past history of myocardial infarction who asks about the purpose of the ECG that has been prescribed? A) "This test will look for heart valve problems. B) 'This test will show how well your heart is pumping" C) "The ECG will tell us how much exercise your heart can tolerate." D) "The ECG will show if there has been damage to the heart muscle."

D) "The ECG will show if there has been damage to the heart muscle."

Which post-traumatic client is in need of counseling after a traumatic event? A) Having difficulty recalling the event B) Having difficulty sleeping one month after the event C) Reporting "feeling numb" 1 week after the event D) Feeling exhausted due to a heavy workload

B) Having difficulty sleeping one month after the event

Which action would the nurse use when a newly admitted client with paranoid ideation talks about people coming through the doors to commit murder? A) Ignore the client when she or he mentions delusions. B) Listen attentively to what the client is saying. C) Explain that no one can get through the door. D) Ask where the information was obtained.

B) Listen attentively to what the client is saying.

Which time interval identifies when the most serious life-threatening effects of alcohol withdrawal occur? A) 8 to 12 hours B) 12 to 24 hours C) 24 to 72 hours D) 72 to 96 hours

C) 24 to 72 hours

When exploring alternative coping strategies during the working phase of the nurse -client relationship, which question would the nurse ask the depressed client who has a history of suicide attempts? A) "How have you managed your problems in the past?" B) "What do you feel that you've learned from this suicide attempt?" C) "How will you manage the next time your problems start piling up?" D) "Were there other things going on in your life that made you want to die?"

C) "How will you manage the next time your problems start piling up?"

A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior? A) 'I'm huge; l'm as big as a house." B) "I get straight A's in all my subjects." C) "My mother keeps trying to get me to eat." D) "My hair is beginning to fall out in clumps."

C) "My mother keeps trying to get me to eat."

Which information would the nurse include as the main reason for drinking alcohol in people with alcohol use disorder? A) They are dependent on it. B) They lack the motivation to stop. C) They use it for coping. D) They enjoy the associated socialization.

A) They are dependent on it.

Which rationale would explain the reason a client abuses alcohol? A) To blunt reality B) To precipitate euphoria C) To promote social interaction D) To stimulate the central nervous system

A) To blunt reality

Which approaches would the nurse use during a crisis intervention interview? Select all that apply. One, some, or all responses may be correct. A) Active B) Passive C) Reflective D) Interpretive E) Goal directed

A) Active E) Goal directed

Which response would the nurse expect from a client diagnosed with antisocial personality disorder? A) "I need a lot of help with my troubles." B) "Society makes people follow rules that don't apply to me." C) "This might help me straighten out my life." D) " don't like to be around other people for long periods of time."

B) "Society makes people follow rules that don't apply to me."

Which finding would alert the nurse that a client diagnosed with schizophrenia is experiencing positive symptoms? Select all that apply. One, some, or all responses may be correct. A) Poverty of speech B) Agitated behavior C) Lack of motivation D) Delusions of grandeur E) Auditory hallucinations

B) Agitated behavior D) Delusions of grandeur E) Auditory hallucinations

Which action would the nurse take for a client who is admitted with conversion disorder? A) Talk about the physical problems. B) Explore ways to verbalize feelings. C) Explain how stress caused the physical symptoms. D) Focus on the client's concerns regarding the symptoms.

B) Explore ways to verbalize feelings.

Which parameter would the nurse consider before confronting a client diagnosed with borderline personality disorder who has been consistently attempting to take advantage of the other clients? A) The last time medication was given B) The depth of their working relationship C) The client's ability to be empathic toward others D) The degree of self-awareness exhibited by the client

B) The depth of their working relationship

Which assessment finding would the nurse evaluate before continuing the administration of intravenous (IV) magnesium sulfate therapy? A) Temperature B) Urinary output C) Urinary glucose D) Level of consciousness

B) Urinary output

Which response would the nurse make to help a depressed client who is crying? A) "Does crying help?" B) "I know that you're upset." C) "Tell me what you're feeling now." D) "Do you want to tell me why you're crying?"

C) "Tell me what you're feeling now."

Which client in a psychiatric unit needs immediate therapeutic intervention? A) A 25-year-old man is mimicking the use of a machine gun in front of the nurse's station. B) A 45-year-old man is sitting quietly in the corner, watching the movements of other clients. C) A 50-year-old woman is pacing back and forth and picking fights with other clients. D) A 33-year-old woman is wandering aimlessly around the unit, saying, "I feel so lost."

C) A 50-year-old woman is pacing back and forth and picking fights with other clients.

Which information would support the nurse's decision to arrange for a staff member to remain with a depressed client continuously? Select all that apply. One, some, or all responses may be correct. A) Refusal to eat any food B) Inability to concentrate C) Agitated pacing in the hall E) History of suicide attempts F) Statements that life is not worth living

C) Agitated pacing in the hall E) History of suicide attempts F) Statements that life is not worth living

The nurse discovers the client with antisocial personality disorder and visitors are smoking marijuana in the hall. Which response would the nurse make when the client responds, "I'm celebrating. I went to trial today and just got put on probation"? A) "You were lucky you just got probation, so don't get right back into trouble." B) "I understand your relief about the trial, but smoking pot is against the rules." C) "t's important that you and your friends join the other visitors in the dayroom." D) "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."

D) "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."

Which response by the nurse uses the technique of paraphrasing when after receiving chemotherapy for non-Hodgkin lymphoma, a client states, "I get so sick to my stomach. The medication is useless."? A) "You get sick to your stomach." B) "Tell me more about how you feel." C) 'I'll get a prescription for an antiemetic." D) "You don't think the medication is helping you."

D) "You don't think the medication is helping you."

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." Which intervention is appropriate for the nurse to take? A)Explain that this reaction is expected and not a concern. B) Take the vital signs and place the client in a high-Fowler position. C) Request stat serum calcium and phosphorus levels and chart the results. D) Test for Chvostek and Trousseau signs and notify the primary health care provider of the complaints.

D) Test for Chvostek and Trousseau signs and notify the primary health care provider of the complaints.