EXAM 2 ATI ch. 35 and 36
Book Ch. 35 ATI Ch. 32 A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters. B. Encourage the client to participate in a support group for survivors of abuse. C. Implement case management to coordinate community and social services. D. Educate the client about the use of stress management techniques.
A
Book Ch. 35 ATI Ch. 33 A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."
A
Book Ch. 36 ATI Ch. 6 A nurse is working in a community mental helath facility. Which of the following services does this type of program provide? (select all that apply) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy
A, B, C, E
Book Ch. 35 ATI Ch. 32 A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing someone to fall is an example of physical violence. C. Striking a sexual partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse.
B
Book Ch. 35 ATI Ch. 33 A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. "Young adults are typical victims of sexual assault." D. "The majority of rapists are unknown to the victims."
B
Book Ch. 36 ATI Ch. 6 A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway. B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia. C. A client in a day treatment program who reports increaing anxiety during group therapy D. A client in a weekly grief support group who reports still missing a deceased partnew who has been dead for 3 months.
B
Book Ch. 35 ATI Ch. 32 A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (Select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference
B, C, D, E
Book Ch. 35 ATI Ch. 32 A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. which of the following findings should alert the nurse to possible abuse? (Select all that apply) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso
B, E
Book Ch. 35 ATI Ch. 33 A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do you feel that you should not have been alone on the street at night?"
C
Book Ch. 36 ATI Ch. 6 A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression. B. Performing screenings for depression at community health programs. C. Establishing rehabilitation programs to decrease the effects of depression. D. Providing suport groups for clients at risk for depression.
C
Book Ch. 36 ATI Ch. 6 A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide. B. Having a weekly visit from a nurse case worker. C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis
C
Book Ch. 36 ATI Ch. 6 A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first? A. A client who received a burn on the arm while using a hot iron at home. B. A client who requests a change of antipsychotic medication due to some new adverse effects. C. A client who reports hearing a voice saying that life is not worth living anymore. D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview
C
Book Ch. 35 ATI Ch. 32 A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at a greater risk for abuse." B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence from a spouse or partner."
D
Book Ch. 35 ATI Ch. 33 A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply) A. Genitourinary soreness B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions
D, E