NUR 104 Exam 3

The nurse is reinforcing discharge instructions for a female client that has a spinal cord injury at the C4 level. Which information should the nurse include with the instructions? A. "After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant." B. "After a spinal cord injury, women are usually unable to conceive a child." C. "Sexual intercourse shouldn't be different for you." D. "After a spinal cord injury, menstruation usually stops."

A. "After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant."

In group therapy, a client who has used intravenous (I.V.) heroin every day for the past year says, "I don't have a drug problem. I can quit whenever I want. I've done it before." The nurse determines that this statement is indicating which defense mechanism? A. Denial B. Obsession C. Compensation D. Rationalization

A. Denial

The nurse attempts to establish a therapeutic relationship with a client in the behavioral health unit. The nurse is reading the client's chart, becomes familiar with the medications the client is taking, and arranges for a meeting. What phase of the nurse-client relationship is the nurse demonstrating? A. orientation phase B. working phase C. termination phase D. confidentiality phase

A. orientation phase

A client informs the nurse that the client has difficulty sleeping. About which conditions does the nurse question the client to determine factors that inhibit adequate sleep patterns? Select all that apply. A. shift work B. sleep apnea C. reduction of external stimuli D. caffeine intake in the evening E. consistent bedtime routine F. Excessive worry or anxiety

A. shift work B. sleep apnea D. caffeine intake in the evening F. Excessive worry or anxiety

A client on an inpatient psychiatric unit refuses to take a medication that has been prescribed. What finding would be the priority before requiring the client to take the medication? A. the client's degree of danger to self or others B. what the "voices" are saying to the client C. whether the client's admission was voluntary or involuntary D. the client's insight into the illness

A. the client's degree of danger to self or others

The nurse is having a conversation with a depressed client. The client states, "Do you think I should tell my family how I feel?" What is the most therapeutic response by the nurse? A. "Of course you should. Honesty is the best policy." B. "Do you think you should tell your family?" C. "I am not sure they would understand, but you could try." D. "I think you should sit them down and talk with them about this."

B. "Do you think you should tell your family?"

The nurse is caring for a client asking for information about cocaine. Which statement by a client indicates that reinforcement of teaching about cocaine use has been effective? A. "I wasn't using cocaine to feel better about myself." B. "I started using cocaine more and more until I couldn't stop." C. "I'm not addicted to cocaine because I don't use it every day." D. "I'm not going to be a chronic user. I only use it on holidays."

B. "I started using cocaine more and more until I couldn't stop."

A client being released from restraints says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate? A. "Do you really mean what you just said?" B. "I'd like to talk with you about your experience." C. "That was the worst thing that ever happened to you?" D. "Someday this experience won't bother you like it does now."

B. "I'd like to talk with you about your experience."

The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question? A. Orientation B. Comprehension C. Concept formation D. General knowledge

C. Concept formation

A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which of the following responses would be best? A. "Well okay, I have a few minutes. I'll take you." B. "I'm sorry but I can't take you. I'm busy." C. "Smoking is harmful to your health. I don't want to contribute to your bad habits." D. "Clients are permitted to smoke at designated times. You'll have to follow the rules."

D. "Clients are permitted to smoke at designated times. You'll have to follow the rules."

While studying for an upcoming examination, which instances would the nursing student review in which sedative-hypnotic drugs are indicated? A. Obsessive-compulsive disorder (OCD) B. Attention deficit hyperactivity disorder (ADHD) C. Hallucinations and delusions D. Anxiety and insomnia

D. Anxiety and insomnia

An older adult client has begun anticonvulsant therapy for the treatment of seizures following a stroke. Which assessment finding is essential to report to the health care provider? A. altered level of consciousness that fluctuates daily B. blood pressure of 130/84 mm Hg C. sleeping frequently throughout the day D. hand tremors making manual dexterity difficult

A. altered level of consciousness that fluctuates daily

A manager observes a nurse interacting with clients on a psychiatric unit. Which nursing action(s) would cause the manager to intervene? Select all that apply. A. talking with a client about personal issues such as the nurse's recent divorce B. spending more time than necessary with a client and showing favoritism C. asking a client to meet for lunch outside the hospital setting D. giving a client the crisis helpline phone number and encouraging the client to call E. posting a picture of the nurse and client on social media

A. talking with a client about personal issues such as the nurse's recent divorce B. spending more time than necessary with a client and showing favoritism C. asking a client to meet for lunch outside the hospital setting E. posting a picture of the nurse and client on social media

A newly hired nurse is assigned to a mental health clinic and is unfamiliar with mental health nursing. The nurse asks another nurse what is the goal of crisis intervention. What is the best response by the nurse? A. "The goal is to solve the client's problems for him or her." B. "The goal is psychological resolution of the immediate crisis." C. "The goal is to establish a means for long-term therapy." D. "The goal is to provide a means for admission to an acute care facility."

B. "The goal is psychological resolution of the immediate crisis."

A nurse is assisting a client with a knowledge deficit about the effects of alcohol on the body. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority? A. Test blood chemistries daily. B. Verbalize the results of substance use. C. Talk to a pharmacist about the substance. D. Attend a weekly aerobic exercise program.

B. Verbalize the results of substance use.

The school nurse is assisting with the performance of screening for children with possible autistic spectrum disorder (ASD). Which child does the nurse determine is at greatest risk for this disorder? A. a child that has a mother and father that are 26-years-old B. a child that has a sibling with ASD C. a child that has had frequent streptococcal pharyngitis D. a child with a congenital heart defect

B. a child that has a sibling with ASD

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? A. "If it had been your emergency, I would have made the other client wait." B. "I know it's frustrating to wait. I'm sorry this happened." C. "Can we talk about how this is making you feel right now?" D. "I really care about you and I'll never let this happen again."

C. "Can we talk about how this is making you feel right now?"

A nurse is trying to determine if a client who uses heroin has any drug-related legal problems. Which question is the best to ask the client? A. "When did your spouse become aware of your use of heroin?" B. "Do you have a probation officer you report to periodically?" C. "Have you received any legal violations related to your drug use?" D. "Do you have a history of frequent visits with the employee assistance program manager?"

C. "Have you received any legal violations related to your drug use?"

A client being treated for morbid obesity is 5' 3" tall and weighs 250 lb (113.4 kg). She has lost 60 lb (27 kg) over the past year. A nurse is advising the client about adding an exercise regimen to her diet program. Which exercise is the most appropriate for the nurse to suggest? A. Aerobics three times per week B. Jogging for 30 minutes three times per week C. Walking for 20 minutes per day D. Weight training for 30 minutes per day

C. Walking for 20 minutes per day

A nurse is reviewing a client's chart and sees a health care practitioner's order for electroconvulsive therapy (ECT). Which following indication would the nurse expect to find that is the appropriate use for this therapy? A. Severe agitation B. Antisocial behavior C. Noncompliance with treatment D. Major depression with psychotic features

D. Major depression with psychotic features

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate? A. Knock on the door and wait to see if someone comes to the door. B. Knock on the door and shout, "It is the nurse. Can I help you?" C. Return to the car and call the family on a cell phone. D. Return to the car and call the police.

D. Return to the car and call the police.

A nurse is developing strategies to prevent relapse with a client who uses alcohol. Which client intervention is important? A. avoiding taking over-the-counter (OTC) medications B. limiting monthly contact with the family C. refraining from becoming involved in group activities D. avoiding people, places, and activities from the former lifestyle

D. avoiding people, places, and activities from the former lifestyle

An appropriate way for the nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the room designated for smoking is to: A. restrict the client's smoking to times when a staff member can supervise closely. B. encourage other clients to speak with the client about keeping the floor clean. C. ask if the client puts out cigarettes on the floor at home. D. hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

D. hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

A client is taking antihypertensive medication and tells the nurse who's monitoring the blood pressure that he can't have sexual intercourse with his wife anymore. What likely cause should the nurse discuss with the client? A. his advancing age B. his blood pressure C. his stressful lifestyle D. his blood pressure medication

D. his blood pressure medication

A nurse knows that gender is part of one's identity. Which event signifies when gender is first ascribed? A. A neonate is born. B. A child attends school. C. A child receives sex-specific toys. D. A child receives sex-specific clothing.

A. A neonate is born.

The nurse is preparing to provide care for a client with bulimia nervosa. Which client symptoms does the nurse anticipate? Select all that apply. A. guilt B. dental caries C. self-induced vomiting D. laxative use E. normal weight F. introverted behavior

A. guilt B. dental caries C. self-induced vomiting D. laxative use E. normal weight

The nurse is interviewing a client on admission to the chemical dependency unit for alcohol detoxification. When asked about alcohol use, the nurse suspects which estimation that this client is most likely to provide? A. Accurately describe the amount consumed B. Underestimate the amount consumed C. Overestimate the amount consumed D. Deny any consumption of alcohol

B. Underestimate the amount consumed

In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. What would be the appropriate response by the nurse? A. "Will you briefly summarize your point to allow time for everyone?" B. "Your behavior is obnoxious and drains the group." C. "We will ignore you as long as you continue to vent." D. "Your behavior is frustrating for the entire group."

A. "Will you briefly summarize your point to allow time for everyone?"

A male client is undergoing estrogen therapy for future sexual reassignment surgery. Which outcome should the nurse assist in evaluating? A. The client will develop breasts. B. The client will begin menstruating. C. The client will be able to cross-dress. D. The client will develop body hair.

A. The client will develop breasts.

The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should: A. encourage verbalizations about fears and stressful life situations. B. agree with the client because she feels a specific physical feature is awful. C. ignore the comment and talk about less threatening issues. D. compliment the client on her appearance.

A. encourage verbalizations about fears and stressful life situations.

A client reports having a strong desire to live and be treated as the opposite sex and is uncomfortable with the current anatomical sex. Based on the client's comments, for what psychiatric condition will the nurse assess? A. transvestic disorder B. gender dysphoria C. paraphilia disorder D. sexual dysfunction

B. gender dysphoria

A client with a diagnosis of bulimia nervosa is working on relationship issues. Which nursing intervention is most important? A. Assist the client to work on developing social skills. B. Help the client identify how relationships cause bulimic behavior. C. Facilitate the client's ability to identify feelings about relationships. D. Discuss ways to prevent getting over-involved in relationships.

C. Facilitate the client's ability to identify feelings about relationships.

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's: A. sincere desire to help others. B. acceptance of others. C. self-awareness and understanding. D. sound knowledge of psychiatric nursing.

C. self-awareness and understanding.

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing? A. Blocker B. Monopolizer C. Recognition seeker D. Aggressor

D. Aggressor

A client was sexually assaulted after returning home from the store late one evening. The client arrives, tearful, at the emergency department. What is the priority intervention for this client? A. Notify the appropriate law enforcement. B. Notify the client's identified support person. C. Ask the client to recount the events. D. Assess the client's physical and mental state.

D. Assess the client's physical and mental state.

The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing? A. Delayed recall B. Remote memory C. Attention level D. Immediate recall

D. Immediate recall

The nurse is preparing to discharge a client with depression from inpatient care. The client tells the nurse, "You helped me more than anyone else in this place. I am hoping you will still be there to help me once I am discharged." How should the nurse respond? A. "I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team." B. "I really like you too and am happy to hear you enjoyed our time together. However, I am not able to stay in contact with you after you are discharged." C. "We discussed the boundaries of the nurse-client relationship when you were admitted to the facility. Did you want to review these rules now?" D. "Have confidence in yourself! You have come a long way and did the work required to improve. I am sure you will continue to do well without me!"

A. "I am glad you found our work together productive. I am confident you will continue to improve with the support of the outpatient program team."

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which client goal is most appropriate for the client? A. Accept responsibility for personal behavior. B. Participate in group therapy. C. Verbalize ways to express anger, such as playing age-appropriate video games. D. Avoid contact with others on the psychiatric forensic unit.

A. Accept responsibility for personal behavior.

A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be? A. Ask the client, "Have you ever acted on these desires?" B. Question the client, "Are you able to control your thoughts about sexual relations with children?" C. Explain that these thoughts are unacceptable and intensive therapy is need. D. Inform child protective services about the client and the thoughts the client reported.

A. Ask the client, "Have you ever acted on these desires?"

A family member visiting on an acute care psychiatric unit approaches the nurse's station and reports that an older adult client is walking in the hall without clothing. Which action should the nurse take first? A. Obtain a blanket or robe with which to cover the client in the hallway. B. Notify the client's nurse of the situation to maintain continuity of care. C. Obtain PRN medication as prescribed for the client to treat agitation. D. Ask the unlicensed assistive personnel to escort the client back to the client's room.

A. Obtain a blanket or robe with which to cover the client in the hallway.

A client with antisocial personality disorder smokes where it's prohibited and refuses to follow other unit and facility rules. The client gets others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this client should focus primarily on: A. consistently enforcing unit rules and facility policy. B. isolating the client to decrease contact with easily manipulated clients. C. engaging in power struggles with the client to minimize manipulative behavior. D. using behavior modification to decrease negative behavior by using negative reinforcement.

A. consistently enforcing unit rules and facility policy.

A client was admitted for treatment of the symptoms of bipolar disorder after failing to comply with community treatment and continuing to expose their sexual partners to a sexually transmitted form of hepatitis. The court appointed a guardian because this client was not able to understand the consequences of the decisions being made. Which terms describes the status of this client? A. legally incompetent B. competent C. voluntary D. emergency involuntary admission

A. legally incompetent

A client tells the nurse she has never had an orgasm and her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate? A. Ask the client if she desires intercourse. B. Assess the couple's perception of the problem. C. Tell the client that most women don't reach orgasm. D. Refer the client to a therapist because she has sexual aversion disorder.

B. Assess the couple's perception of the problem.

A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5' 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which approach should the nurse take first when caring for this client? A. Teach the client about nutrition, calories, and a balanced diet. B. Establish a trusting relationship with the client. C. Discuss cultural stereotypes regarding thinness and attractiveness. D. Explore the reasons why the client doesn't eat.

B. Establish a trusting relationship with the client.

A nurse working on the substance abuse unit is encouraging a client to attend Alcoholics Anonymous (AA) meetings. When the client asks the nurse what must be done to become a member, what response is most appropriate? A. "You must first stop drinking before anything else." B. "Your primary care provider must refer you to this program." C. "Admit you're powerless over alcohol and you need help." D. "You must bring along a friend who will support you."

C. "Admit you're powerless over alcohol and you need help."

After completing chemical detoxification and a 12-step program to treat drug addiction, a client is being prepared for discharge. Which remark by the client indicates to the nurse that he or she has a realistic view of the future? A. "I'm never going to use crack again." B. "I know what I have to do. I have to limit my crack use." C. "I'm going to take 1 day at a time. I'm not making any promises." D. "I can't touch crack again, but I sure could use a drink. I've earned it."

C. "I'm going to take 1 day at a time. I'm not making any promises."

An adult client arrives at the emergency department and has just learned that a parent has died as a result of an automobile accident. The client states, "No, I don't believe it. It can't be true." How should the nurse respond? A. "It is normal to experience denial when given such news." B. "You are in shock right now. Give yourself some time." C. "This is shocking news. May I sit with you for a while?" D. "Would you like to see your mother's body now?"

C. "This is shocking news. May I sit with you for a while?"

A client being treated for infertility confides to the nurse that they haven't told their partner about being treated for a sexually transmitted infection in the past. What would be the most therapeutic response for the nurse to give? A. "Are you fearful of how your partner will react to this information?" B. "Did you expose your current partner to this infection?" C. "What concerns do you have about sharing this information?" D. "It is your choice related to what health information you share."

C. "What concerns do you have about sharing this information?"

A group of college students was walking back to their dorm at night when a stranger indecently exposes themselves to the group. One of the students became extremely upset and went to the clinic. Which response by the nurse would be most therapeutic? A. "Have you ever had an experience like this before?" B. "I will call security right away so you can report the incident." C. "You appear upset. Can you tell me more about this?" D. "Do you know the person who exposed themselves to you?"

C. "You appear upset. Can you tell me more about this?"

Nursing care for a client after electroconvulsive therapy (ECT) should include: A. nothing by mouth for 24 hours after the treatment because of the anesthetic agent. B. bed rest for the first 8 hours after a treatment. C. assessment of short-term memory loss. D. no special care.

C. assessment of short-term memory loss.

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate? A. "I need to ask you the questions on the database." B. "It's your right not to answer my questions." C. "OK, I'll just write 'no comment.'" D. "I know this must be difficult for you."

D. "I know this must be difficult for you."

A client is admitted to a psychiatric unit in a state of emotional distress after his wife filed for divorce and he lost his job. Which assessment should take priority for this client? A. Determine why the client lost his job. B. Develop a plan for coping with the crisis event. C. Perform antianxiety interventions. D. Identify the client's perception of the event.

D. Identify the client's perception of the event.

Assertive behavior involves which of the following elements? A. Saying what is on your mind at the expense of others B. Expressing an air of superiority C. Avoiding unpleasant situations and circumstances D. Standing up for your rights while respecting the rights of others

D. Standing up for your rights while respecting the rights of others

A client is in the emergency department after being sexually assaulted by a stranger. Which nursing intervention has priority? A. helping identify which behaviors placed the client at risk for the attack B. making an appointment in 6 weeks at a local sexual assault crisis center C. encouraging discussion of early childhood experiences D. assisting in identifying family or friends who could provide immediate support

D. assisting in identifying family or friends who could provide immediate support

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to: A. establish a rapport to foster trust. B. place the client in full leather restraints. C. try to communicate with the client in writing. D. ensure safety by initiating suicide precautions.

D. ensure safety by initiating suicide precautions.

The nurse is creating a nurse-client contract for a client in an outpatient cognitive-behavioral therapy (CBT) program. What are valid examples of information the nurse would include in the contract? Select all that apply. A. There will be ten sessions in total taking place at the clinic on Tuesdays from 2-3 p.m. weekly. B. If you are more than 15 minutes late, you will not be able to join the session that week. C. No information will be shared outside the treatment team without your permission. D. Weekly assignments in the CBT workbook will be due at the beginning of the next session. E. Parking is available on the west side of the building, and the bus stop number is 1234.

A. There will be ten sessions in total taking place at the clinic on Tuesdays from 2-3 p.m. weekly. B. If you are more than 15 minutes late, you will not be able to join the session that week. C. No information will be shared outside the treatment team without your permission. D. Weekly assignments in the CBT workbook will be due at the beginning of the next session.

A nurse is conducting a sexual awareness group of known pedophiles. What will the nurse highlight as the primary focus of this group? A. socialization B. cognitive restructuring C. insight D. punishment

B. cognitive restructuring

The nurse is educating the client who is close to the termination phase of a therapeutic nurse-client relationship. Which nursing intervention is most appropriate during this phase? A. Tell the client there is no further need for support groups. B. Address new issues with the client. C. Review what has been accomplished during this relationship. D. Avoid discussing the client's emotions.

C. Review what has been accomplished during this relationship.

A nurse is using drawing, puppetry, and other forms of play therapy while caring for a terminally ill, school-age child. What is the primary nursing goal of play therapy for this child? A. internalization of feelings about death and dying B. acceptance of responsibility for the illness C. expression of feelings that the child cannot articulate D. experiencing a good time while hospitalized

C. expression of feelings that the child cannot articulate

A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check? A. Adequate time has elapsed between discontinuing the first medication and beginning the second. B. The MAOI is initiated at the same dosage as the tricyclic antidepressant (TCA). C. The client is free of suicidal thoughts and ideation. D. The client is not allergic to cheese.

A. Adequate time has elapsed between discontinuing the first medication and beginning the second.

A hospitalized client becomes angry and belligerent toward a nurse after speaking on the phone with the parent. The nurse learns that the parent cannot visit as expected. Which interventions might the nurse use to help the client deal with the displaced anger? Select all that apply. A. Explore the client's unmet needs. B. Avoid the client until and apology is made. C. Suggest that the client direct the anger at the parent. D. Invite the client to a quiet place to talk. E. Assist the client in identifying alternate ways of approaching the problem.

A. Explore the client's unmet needs. D. Invite the client to a quiet place to talk. E. Assist the client in identifying alternate ways of approaching the problem.

The nurse, along with the treatment team for the client, uses critical pathways of care. Which statement regarding critical pathways is correct? A. It is a care plan that provides outcome-based guidelines with a designated length of stay. B. It is an outline of care designed for physicians to order medications, treatments, and activity levels. C. It is a design of treatment that includes approved therapies and critical use of nontraditional therapies. D. It is a holistic therapy technique that combines the use of meditation along with an emphasis on treatment team collaboration.

A. It is a care plan that provides outcome-based guidelines with a designated length of stay.

A caregiver is suspected of neglect and abuse. What warning signals should the nurse document and report? Select all that apply. A. The caregiver does not allow the client to speak for him or herself, have visitors, or be alone with others. B. The caregiver places blame on the client for his or her illness or limitations. C. The caregiver informs the nurse that he or she is having trouble obtaining supplies for care. D. The caregiver has alcohol on his or her breath and acts as though he or she is impaired. E. The caregiver states that he or she would like to go visit a friend for a week.

A. The caregiver does not allow the client to speak for him or herself, have visitors, or be alone with others. B. The caregiver places blame on the client for his or her illness or limitations. D. The caregiver has alcohol on his or her breath and acts as though he or she is impaired.

A client is brought to the crisis center by family members after giving away all of the family's possessions. When gathering data from the client, which statement would lead the nurse to suspect possible suicidal ideation? A. "My brother didn't call on my birthday. I don't think he loves me anymore." B. "There's no hope. I feel like going to sleep and never waking up." C. "I'm such a loser. I really feel like a total failure." D. "I don't want to think about my problems any longer."

B. "There's no hope. I feel like going to sleep and never waking up."

An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client? A. "I'm sorry. The chart is the property of the facility. We don't permit clients to read their charts." B. "You have the right to see your chart. Please discuss your wish with your physician." C. "You may see your chart after you're discharged." D. "Please discuss this matter with your attorney."

B. "You have the right to see your chart. Please discuss your wish with your physician."

A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time? A. Impaired adjustment B. Anxiety C. Impaired verbal communication D. Powerlessness

B. Anxiety

After learning that a roommate has tested positive for the human immunodeficiency virus (HIV), a client asks a nurse about moving to another room on the psychiatric unit because the client does not feel "safe" now. What should the nurse do first? A. Move the client to another room. B. Ask the client to describe their fears C. Move the client's roommate to a private room. D. Explain that such a move wouldn't be therapeutic for the client or his roommate.

B. Ask the client to describe their fears

Which information is most important for the nurse to reinforce with a client who abuses prescription drugs? A. Herbal substitutes are safer to use. B. Medication should be used only for the reason prescribed. C. The client should consult a health care provider before using a drug. D. Consider if family members influence the client to use drugs.

B. Medication should be used only for the reason prescribed.

When presenting a lecture on anxiety, which term would a nursing instructor use that refers to the primary unconscious defense mechanism which keeps intense anxiety-producing situations out of a person's conscious awareness? A. Introjection B. Regression C. Repression D. Denial

B. Regression

A nurse learns that another staff nurse in an outpatient mental health clinic has recently sought money from a group of mental health center clients to invest in a new business. How should the nurse respond to learning this information? A. Take over the care of the nurse's clients. B. Report concerns to the nursing supervisor. C. Call the board of nursing to report the coercion of vulnerable clients into business deals. D. Contact the media to file a "consumer report" on the multilevel marketing scam.

B. Report concerns to the nursing supervisor.

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. The nurse realizes this client is demonstrating which type of behavior? A. Confidentiality B. Splitting C. Empathy D. Gnawing

B. Splitting

A client is admitted to the psychiatric unit with a history of obsession regarding weight, bingeing, and purging after eating. The client's weight has been stable at 96 lb (43.5 kg) and determined to be normal for height. The nurse reviews these findings with the understanding that they may be most likely associated with which disorder? A. anorexia nervosa B. bulimia C. Kleine-Levin syndrome D. dysthymia

B. bulimia

A client comes to the clinic for right shoulder pain. The nurse observes bruises resembling fingerprints on several areas of the right arm and bruising on the back. The client has a history of similar injuries in the past. What questions would be important for the nurse to ask? Select all that apply. A. "Have you done anything to incite this type of behavior from your spouse?" B. "You need to leave this person before they kill you. Do you have somewhere to go?" C. "Are you in a relationship that makes you afraid or unsafe?" D. "People in relationships argue. What happens when you and your partner argue?" E. "If you are in danger now, would you like help in locating a shelter?"

C. "Are you in a relationship that makes you afraid or unsafe?" D. "People in relationships argue. What happens when you and your partner argue?" E. "If you are in danger now, would you like help in locating a shelter?"

The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder? A. "I know what you mean. You put a lot of energy into working with our client. It must be disappointing to have the client do something like this." B. "I could have told you this would happen. A client like this one always gets you in the end." C. "Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety." D. "I know what you mean. I hope this will teach you not to get so involved with a client's welfare."

C. "Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."

A client recovering from cocaine use is participating in group therapy. Which statement by the client indicates that the client has benefited from the group? A. "I think the laws about drug possession are too strict in this country." B. "I'll be more careful about mentioning my drug use to my children." C. "I finally realize the short high from cocaine isn't worth the depression." D. "I can't understand how I could get all these problems that we talked about in group."

C. "I finally realize the short high from cocaine isn't worth the depression."

The nurse educator is presenting an in-service on unhealthy boundaries. The educator will discuss how unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Which factor should the educator include that indicates unhealthy boundaries may also be a result of? A. Structured limit-setting B. Supportive environment C. Abuse and neglect D. Direction and attention

C. Abuse and neglect

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What about the client's ability to think is being assessed by the health care practitioner? A. Client's ability to think rationally B. Client's ability to think concretely C. Client's ability to think abstractly D. Client's ability to think tangentially

C. Client's ability to think abstractly

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? A. Pretend not to know the client. B. Let the client establish the rules. C. Discuss this to define the relationship. D. Stop attending this support group.

C. Discuss this to define the relationship.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? A. Read several articles about the client's culture. B. Ask staff members of a similar culture about the client's behavior. C. Observe how the client and his family and friends interact with each other and with other staff members. D. Accept the client's behavior because it's probably culturally based.

C. Observe how the client and his family and friends interact with each other and with other staff members.

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate? A. Schedule a weekly meeting with the children to monitor their situation. B. Call the mother and request a conference. C. Report the information to child protective services. D. Notify the grandfather, a local physician, to solicit help for his grandchildren.

C. Report the information to child protective services.

A client is admitted to a substance abuse unit for alcohol detoxification and is asked when they had an alcoholic drink. The client states, "Six hours prior to admission." Based on this response, when should the nurse expect early withdrawal symptoms to occur? A. not at all B. within the next 24 to 48 hours C. within 2 to 7 days D. after the first week

C. within 2 to 7 days

A nurse is caring for a client with antisocial personality disorder. The client states to the nurse, "When I leave here, I want to take you on a date. You have been the best nurse in this place." What is the best response by the nurse? A. "You have been told the rules about not speaking to staff in this way." B. "Would you like to discuss why you are choosing manipulative behaviors?" C. "It is against facility policy for nurses to have relationships with clients." D. "That type of relationship is not appropriate between a nurse and a client."

D. "That type of relationship is not appropriate between a nurse and a client."

An older adult client has been admitted to the acute care unit with new-onset delirium. What statement made by the caregiver should be relayed to the healthcare provider? A. "The client is taking medication for the treatment of hypertension." B. "I took the client out for a ride to the store yesterday." C. "The client informed me 2 days ago of neck discomfort." D. "When I was toileting the client, the urine had a very strong odor."

D. "When I was toileting the client, the urine had a very strong odor."

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition? A. Feelings B. Blocking C. Mood D. Affect

D. Affect

A local high school recently identified a problem with alcohol-related accidents among student drivers; two of these accidents resulted in death. School officials developed a plan to address the problem. The school nurse begins her part by addressing primary prevention. Which intervention by the school nurse is appropriate? A. Working with school administrators to provide a time and place for Al-Anon meetings B. Arranging for a local telephone number for teenagers to call regarding counseling C. Asking local law enforcement officials to provide officers for the school D. Arranging for a presentation by a local teenager who was involved in an alcohol-related traffic fatality

D. Arranging for a presentation by a local teenager who was involved in an alcohol-related traffic fatality

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action? A. Administering the medication by injection B. Omitting the dose and trying again the next day C. Crushing the medication and putting it in his food D. Consulting with the physician about a plan of care

D. Consulting with the physician about a plan of care

A client with an antisocial personality disorder exhibits manipulative behavior. When assisting with the development of the plan of care, which intervention would most likely be included? A. Freedom to do as the client chooses when behavior improves B. Limitations per unit rules without restrictions for broken rules C. Reasonable expectations with varying limits D. Verbal reinforcement when the client functions within established limits

D. Verbal reinforcement when the client functions within established limits

The terms "judgment" and "insight" are sometimes used incorrectly. How would the nurse appropriately define insight? A. The ability to make appropriate choices B. The ability to control inappropriate impulses C. The ability to explain one's psychiatric diagnosis D. The ability to understand the nature of one's problem or situation

D. The ability to understand the nature of one's problem or situation

A client who identifies as gay tells the nurse, "My family is not supportive." What is the best response by the nurse? A. "What do you mean by not supportive?" B. "They will understand later." C. "How do they treat you?" D. "Would you like to arrange for counseling?"

A. "What do you mean by not supportive?"

A client arrives in the emergency department via rescue squad with a suspected opiate overdose. Which medication prescribed by the health care provider does the nurse prepare to administer? A. bupropion B. fluoxetine C. diazepam D. naloxone

D. naloxone

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client? A. further education B. conflict resolution C. career development D. personal development

D. personal development

A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the nurse expects the health care practitioner to most likely prescribe which drug? A. Clozapine B. Thiothixene C. Lorazepam D. Lithium carbonate

C. Lorazepam

A postpartum client has been ordered 500 mg of ampicillin oral suspension. The label reads ampicillin 125 mg/5 mL. How many milliliters should the client receive? Record your answer using a whole number.

20 mL

A client is prescribed chlordiazepoxide as needed to control the symptoms of alcohol withdrawal. Which symptoms may indicate the need for an additional dose of this medication? (Select all that apply.) A. tachycardia B. mood swings C. elevated blood pressure and temperature D. piloerection D. tremors E. Increasing anxiety.

A. tachycardia C. elevated blood pressure and temperature D. tremors E. Increasing anxiety.

A client who gave birth by cesarean 3 days ago is bottle-feeding her neonate. While collecting data, the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, small amount of lochia rubra, and the client reports discomfort in her breasts, which are hard and warm to touch. Which action would be most appropriate? A. Encourage the client to wear a supportive bra. B. Have the client stand in a warm shower. C. Inform the health care provider that the client is showing early signs of breast infection. D. Recommend use of a breast pump to facilitate removal of stagnant breast milk.

A. Encourage the client to wear a supportive bra.

A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? A. "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." B. "If I lose my temper in the community room, I'll be locked up in the seclusion room." C. "When I go into seclusion, I won't be able to see my physician until I calm myself down." D. "Every time I decide that I won't attend a group meeting, I'll be put in seclusion."

A. "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room."

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution? A. Encourage the mother to breast feed. B. Encourage a sitz bath daily. C. Increase fluid intake. D. Encourage bed rest.

A. Encourage the mother to breast feed.

A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight with a parent. Which nursing intervention would be most helpful? A. Examine the relationship between feelings and eating. B. Discuss the importance of therapy for the entire family. C. Encourage the client to avoid certain family members. D. Don't fight with parents.

A. Examine the relationship between feelings and eating.

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate? A. "It isn't unusual to have those feelings after delivery." B. "How have you coped with other problems in your life?" C. "To whom do you usually talk when you have problems?" D. "Don't worry. You'll be fine."

A. "It isn't unusual to have those feelings after delivery."

One week after giving birth, a client comes to the clinic for a check up. The client tearfully tells the nurse, "I should feel happy, but I don't. What's wrong with me?" Which response by the nurse would be best? A. "It's not unusual to have these feelings after giving birth." B. "How have you coped with other problems in your life?" C. "Who do you usually talk to when you have problems?" D. "Don't worry. You'll be fine."

A. "It's not unusual to have these feelings after giving birth."

A nurse is caring for a client who abuses alcohol. Which fact should the nurse communicate to the client about treatment for the client's condition? A. Abstinence is the basis for successful treatment. B. Daily attendance at Alcoholics Anonymous (AA) meetings cures alcoholism. C. Family members must participate for treatment to be successful. D. An occasional social drink is acceptable behavior for an alcoholic.

A. Abstinence is the basis for successful treatment.

One day after having a cesarean birth, a client reports incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug? A. Administer the drug with meals or milk. B. Obtain the client's pulse rate before administering the drug. C. Monitor the client's blood pressure to assess for hypotension. D. Instruct the client about ways to prevent orthostatic hypotension.

A. Administer the drug with meals or milk.

The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important? A. Assessing fundal tone and lochia flow B. Applying a cold pack to the perineal area C. Administering analgesics, as ordered D. Encouraging the client to void by offering the bedpan

A. Assessing fundal tone and lochia flow

One day after a client gives birth, the nurse performs a postpartum assessment. The nurse finds a moderate amount of lochia rubra on the client's perineal pad. Which action should the nurse? A. Document this as a normal finding B. Notify the health care provider C. Massage the fundus D. Obtain vital signs

A. Document this as a normal finding

The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond? A. Tell the mother to ignore the child because eventually he will stop having temper tantrums. B. Tell the mother to promise him a new toy if he stops the tantrum. C. Tell the mother to give in to his demands; he is only 3-years-old. D. Tell the mother to mimic him so that he can see what his behavior looks like.

A. Tell the mother to ignore the child because eventually he will stop having temper tantrums.

A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent assessment finding associated with early alcohol withdrawal would the nurse expect to find? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mm Hg D. Blood pressure of 140/80 mm Hg

A. Heart rate of 120 to 140 beats/minute

Which nursing action is most appropriate for the nurse to utilize when trying to diffuse a client's impending violent behavior? A. Helping the client identify and express feelings of anxiety and anger B. Involving the client in a quiet activity to divert attention C. Leaving the client alone until the client can talk about his or her feelings D. Placing the client in seclusion

A. Helping the client identify and express feelings of anxiety and anger

How can the nurse help a client with anorexia nervosa recognize distortions of thought? A. Identify the client's misperceptions of self. B. Acknowledge immature and childlike behaviors. C. Determine the consequences of a faulty support system. D. Explain why healthy eating is important.

A. Identify the client's misperceptions of self.

A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5' 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention that takes highest priority would the nurse implement? A. Initiating caloric and nutritional therapy as ordered B. Instituting behavioral modification therapy as ordered C. Addressing the client's low self-esteem D. Developing a contract with the client that permits privileges with weight gain

A. Initiating caloric and nutritional therapy as ordered

When monitoring a postpartum client 2 hours after birth of her newborn, the nurse notices heavy bleeding with large clots. Which action would the nurse perform first? A. Massage the fundus firmly. B. Perform bimanual compression. C. Administer ergonovine. D. Notify the primary health care provider.

A. Massage the fundus firmly.

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding? A. Massage the fundus. B Replace the pad and apply pressure to the vagina. C. Increase the IV fluids. D. Administer oxytocin as ordered.

A. Massage the fundus.

The nurse is caring for a client who has bulimia. What is a common metabolic complication associated with bulimia? A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis

A. Metabolic alkalosis

The nurse is caring for an adolescent client receiving a selective serotonin reuptake inhibitor (SSRI) as part of the treatment plan for anorexia nervosa. Which action is a priority intervention related to the SSRI therapy? A. Monitor for suicidal thoughts. B. Weigh the client regularly. C. Document the food intake without comment. D. Explore the client's strengths and positive coping mechanisms.

A. Monitor for suicidal thoughts.

On her third postpartum day, a client says she has chills and aches. Her chart shows that she has had a temperature of 38.1° C (100.6° F) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do first? A. Obtain a vaginal swab for culture B. Start IV antibiotics C. Start a sitz bath D. Give aspirin PRN

A. Obtain a vaginal swab for culture

The nurse is caring for a client who exhibits pinpoint pupils and decreased blood pressure, pulse, respirations, and temperature. These signs may indicate which disorder? A. Opiate intoxication B. Amphetamine intoxication C. Cannabis intoxication D. Alcohol intoxication

A. Opiate intoxication

Lochia normally progresses in which of the following patterns? A. Rubra, serosa, alba B. Serosa, rubra, alba C. Serosa, alba, rubra D. Rubra, alba, serosa

A. Rubra, serosa, alba

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

A. Seizures

A nurse is caring for a client who delivered a healthy full-term baby 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? A. Tachycardia and hypotension B. Gush of vaginal blood when the client stands up C. Blood stain 2" (5.1 cm) in diameter on the abdominal dressing D. Reports of abdominal pain

A. Tachycardia and hypotension

The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day? A. The client asks many questions about the baby's care. B. The client wants to relate her birth experience. C. The client asks the nurse to select her meals for her. D. The client asks the nurse to help her bathe herself.

A. The client asks many questions about the baby's care.

A nurse is caring for a client with anorexia nervosa. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority? A. The client will establish adequate daily nutritional intake. B. The client will make a contract with the nurse that sets a target weight. C. The client will identify self-perceptions about body size as unrealistic. D. The client will verbalize the possible physiological consequences of self-starvation.

A. The client will establish adequate daily nutritional intake.

A nurse is reviewing instructions for perineal care with a client. Which action indicates that the client understands proper perineal care? A. Uses a peri bottle to cleanse the perineum after each voiding or bowel movement. B. Cleanses the perineum from back to front after a bowel movement. C. Cleanses with baby wipes after a bowel movement. D. Changes perineal pads every 8 hours.

A. Uses a peri bottle to cleanse the perineum after each voiding or bowel movement.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? A. Using a peri bottle to clean the perineum after each voiding or bowel movement B. Cleaning the perineum from back to front after a bowel movement C. Spraying water from peri bottle into the vagina D. Changing perineal pads every 8 hours

A. Using a peri bottle to clean the perineum after each voiding or bowel movement

The nurse visits a client at home on the tenth postpartum day. When assessing the client's uterus, the nurse expects to find: A. a nonpalpable fundus in the abdomen. B. a fundus palpable two fingerbreadths above the umbilicus. C. a fundus palpable at the umbilicus. D. a fundus palpable one fingerbreadth below the umbilicus.

A. a nonpalpable fundus in the abdomen.

Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which of the following nursing interventions should the nurse implement to promote healing? Select all that apply. A. applying cold to limit edema during the first 12 to 24 hours B. instructing the client to use two or more peripads to cushion the area C. instructing the client on the use of sitz baths D. instructing the client about the importance of perineal (Kegel) exercises E. increasing fiber in the diet to prevent constipation

A. applying cold to limit edema during the first 12 to 24 hours C. instructing the client on the use of sitz baths D. instructing the client about the importance of perineal (Kegel) exercises E. increasing fiber in the diet to prevent constipation

An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. When obtaining data, which behaviors would be characterized as compulsions? Select all that apply. A. checking and rechecking that the television is turned off before going to school B. repeatedly washing the hands C. brushing teeth three times per day D. routinely climbing up and down a flight of stairs three times before leaving the house E. feeding the dog the same meal every day F. wanting to play the same video game each night

A. checking and rechecking that the television is turned off before going to school B. repeatedly washing the hands D. routinely climbing up and down a flight of stairs three times before leaving the house

A nurse is assisting a postpartum client to breast-feed her newborn. The client is having difficulty in establishing an adequate supply of breast milk. The nurse understands that which factor might play a role? A. supplemental formula feedings B. maternal diet high in vitamin C C. an alcoholic drink D. frequent feedings

A. supplemental formula feedings

The nurse is working with a client who has a heroin addiction. What is an underlying cause common to most abusers? A. difficulty in effectively coping with stress B. difficulty in effectively interacting socially C. difficulty in effectively performing in work-related settings D. difficulty in effectively setting limits

A. difficulty in effectively coping with stress

The nurse is caring for a postpartum client after giving birth to a healthy neonate. When checking the client's fundus, which finding would the nurse most likely note? A. fundus 1 cm above the umbilicus 1 hour postpartum B. fundus 1 cm above the umbilicus on postpartum day 3 C. fundus palpable in the abdomen at 2 weeks postpartum D. fundus slightly to right; 2 cm above umbilicus on postpartum day 2

A. fundus 1 cm above the umbilicus 1 hour postpartum

A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications? A. gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl B. gravida 2 para 2011, cesarean birth, incision site intact, pulse 84 beats/minute C. gravida 1 para 2001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7° C) D. gravida 1 para 2001, vaginal delivery, membranes ruptured 10 hours before birth

A. gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl

A nurse is obtaining data for physical health problems in a client who uses heroin. Which medical consequence of heroin does the nurse recognize commonly occurs? A. hepatitis B. peptic ulcers C. hypertension D. chronic pharyngitis

A. hepatitis

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client? A. learning to express feelings B. establishing new roles in the family C. determining new strategies for socializing D. decreasing preoccupation with physical health

A. learning to express feelings

An Rh-positive client gives birth vaginally to a 6-lb, 10-oz (3,007-g) neonate after 17 hours of labor and after membranes have been ruptured. The nurse monitors the client for possible infection based on the understanding that the client is at risk due to which factor? A. length of labor B. maternal Rh status C. method of birth D. size of the neonate

A. length of labor

A postpartum client experiences postpartum hemorrhage. Fundal massage has failed to maintain uterine contraction, and the client continues to experience hemorrhage. The nurse would anticipate which medications to be prescribed? Select all that apply. A. oxytocin B. carboprost C. methylergonovine D. heparin E. amoxicillin

A. oxytocin B. carboprost C. methylergonovine

The nurse's goal in crisis intervention is to provide: A. problem-solving techniques and structured activities. B. an insight-oriented analytic approach. C. medication to sedate the client. D. nondirective techniques such as free association.

A. problem-solving techniques and structured activities.

A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day? A. red with moderate flow B. continuous flow with red clots C. brown and scant amount D. thin consistency and white in color

A. red with moderate flow

A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication? A. severe pre-eclampsia B. urinary retention C. Rhogam administration D. fetal decelerations

A. severe pre-eclampsia

The nurse is working on a postpartum unit with a newly hired unlicensed assistive personnel (UAP). For which action(s) by the UAP will the nurse intervene? Select all that apply. A. transporting a newborn to the nursery using a cradled arm carrying technique B. teaching a new mother about proper latching during breastfeeding C. providing the client with an ice pack for application to the perineum D. assisting the client with an indwelling urinary catheter into the washroom E. assisting the client with setting up the equipment for a sitz bath

A. transporting a newborn to the nursery using a cradled arm carrying technique B. teaching a new mother about proper latching during breastfeeding

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. Based on this finding, the nurse would anticipate which test as the priority? A. venous duplex ultrasound of the right leg B. transthoracic echocardiogram C. venogram of the right leg D. noninvasive arterial studies of the right leg

A. venous duplex ultrasound of the right leg

A client has just given birth to her first child. The client is Rho(D)-negative and her baby is Rh-positive. At which time would the nurse most likely expect Rho(D) immune globulin IM to be given to the mother to reduce the risk of Rh incompatibility? A. within 72 hours B. within 1 week postpartum C. at her 6-week postpartum visit D. after 3 months

A. within 72 hours

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate? A. Reassess the client in 2 hours. B. Administer oxytocin as prescribed. C. Massage the uterine fundus gently. D. Notify the physician or nurse-midwife.

C. Massage the uterine fundus gently.

A client with a psychiatric disorder was voluntarily admitted and now wishes to be discharged from the hospital, against medical advice. Which aspect would be most important for the nurse to determine in this situation? A. ability to care for self B. degree of danger to self and others C. level of psychosis D. intended compliance with aftercare

B. degree of danger to self and others

A client is brought to the emergency department after being sexually assaulted by a rival gang member. The nurse observes that the client appears relaxed and is calmly talking to a relative. The nurse determines that the client may be using which defense mechanism? A. rationalization B. denial C. displacement D. projection

B. denial

A nurse is caring for a client who is undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse determine the client is using? A. projection and suppression B. denial and rationalization C. rationalization and repression D. suppression and denial

B. denial and rationalization

A client with a history of bulimia nervosa is hospitalized for observation. For which complication will the nurse monitor? A. decreased amylase B. electrolyte imbalance C. hyperglycemia D. increased white blood count

B. electrolyte imbalance

A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse? A. "It's important to observe these types of behaviors and make necessary referrals to the social worker." B. "Extreme fatigue from the delivery is common, and mothers often focus initially on recovery and taking in the birth experience." C. "Make sure you don't assume the care for the baby. Encourage the mother to change diapers and take responsibility for feeding." D. "It's sad that some women don't seem to appreciate the gift of a healthy baby."

B. "Extreme fatigue from the delivery is common, and mothers often focus initially on recovery and taking in the birth experience."

A client with bulimia nervosa asks a nurse, "How can I ask for help from my family?" Which response is most appropriate? A. "When you ask for help, make sure you really need it." B. "Have you ever asked your family for help in the past?" C. "Ask family members to spend time with you at mealtime." D. "Think about how you can handle this situation without help."

B. "Have you ever asked your family for help in the past?"

A client with alcoholism has just completed a residential treatment program. Which client statement reflects that treatment has been effective? A. "I am glad my family will no longer be dysfunctional." B. "I need ongoing support to remain sober." C. "I am so happy to be free from alcoholism." D. "I can now drink an alcoholic beverage once in a while without problems."

B. "I need ongoing support to remain sober."

A postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. After assisting with the discharge teaching plan, the nurse determines that the client has understood the information when what statement is made? A. "I need to avoid taking any iron supplements." B. "I should not take any over-the-counter (OTC) salicylates." C. "It's important for me to wear knee-high stockings when possible." D. "Shortness of breath is a common adverse effect."

B. "I should not take any over-the-counter (OTC) salicylates."

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? A. "If you don't attempt to void, I'll need to catheterize you." B. "It's common for you to have a full bladder even though you can't sense it." C. "I'll need to contact your health care provider right away for instructions." D. "I'll come back and check on you in a few hours to see if you can go."

B. "It's common for you to have a full bladder even though you can't sense it."

A new mother who's breast-feeding asks how she can quickly lose the 40 lb she gained during pregnancy. Which response by the nurse is best? A. "The extra calories expended during breast-feeding will allow you to lose the weight gradually and effortlessly over the next few months." B. "It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended." C. "Breast-feeding mothers should diet until their babies are weaned." D. "Relax and enjoy your infant. You shouldn't be worrying about your weight."

B. "It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."

A client reports being involved in a motor vehicle accident while intoxicated. Which nursing response is therapeutic? A. "Why didn't you choose for someone else to drive you?" B. "Tell me how you feel about the accident." C. "I'm sure you have been taught about the dangers of drinking and driving." D. "It will be very important for you to attend Alcoholics Anonymous meetings in the future."

B. "Tell me how you feel about the accident."

When reviewing self-care instructions with a postpartum client, the nurse emphasizes the need for the client to report heavy or excessive bleeding. The nurse would describe "heavy bleeding saturating one sanitary pad" within which time span? A. 4 hours B. 1 hour C. 6 hours D. 8 hours

B. 1 hour

The nurse is observing a new mother interact with her baby for the first time approximately 1 hour after the baby's birth. Upon receiving the baby, the mother begins to undress her baby. Which of the following should the nurse do? A.. Call the pediatrician and report the behavior. B. Anticipate and support the behavior as a normal part of bonding. C. Encourage the mother to rewrap the baby because the room is cold. D. Take the baby back to the nursery and recheck the baby's temperature.

B. Anticipate and support the behavior as a normal part of bonding.

When gathering data of a client who gave birth 3 hours ago, a nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which nursing actions would be appropriate? Select all that apply. A. Begin an I.V. infusion of lactated Ringer's solution. B. Assess the client's vital signs. C. Palpate the client's fundus. D. Place the client in high Fowler's position. E. Administer a pain medication.

B. Assess the client's vital signs. C. Palpate the client's fundus.

A client is struggling with alcohol dependence. Which communication strategy is most effective for the nurse? A. Speak briefly and directly. B. Avoid blaming or lecturing the client. C. Confront feelings and examples of perfectionism. D. Determine if nonverbal communication will be more effective.

B. Avoid blaming or lecturing the client.

A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take? A. Notify the client's family. B. Call the police. C. Call the nursing supervisor. D. Ask the client to discuss the matter privately.

B. Call the police.

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry

B. Calling a security guard and another staff member for assistance

A nurse is caring for a client with a warm, reddened, painful area in the breast as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding. Which instructions should the nurse include to prevent a recurrence of this condition? Select all that apply. A. Wash the nipples with soap and water. B. Change the breast pads frequently. C. Expose the nipples to air for part of each day. D. Wash hands before handling the breast and breast-feeding. E. Make sure that the baby grasps the nipple only. F. Release the baby's grasp on the nipple before removing the baby from the breast.

B. Change the breast pads frequently. C. Expose the nipples to air for part of each day. D. Wash hands before handling the breast and breast-feeding. F. Release the baby's grasp on the nipple before removing the baby from the breast.

The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action? A. Ensure that this is a mutually agreed upon decision. B. Discuss the situation with the nursing student after the visit has ended. C. Ask the client and student who initiated the idea for these arrangements. D. Immediately report the incident to the student's professor.

B. Discuss the situation with the nursing student after the visit has ended.

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take? A. Obtain vital signs B. Encourage the client to breast feed the baby more frequently and regularly. C. Send the breast milk for culture and sensitivity D. Assist the client to apply a cold compress to the breast

B. Encourage the client to breast feed the baby more frequently and regularly.

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby? A. Be selective in providing the information that the client seeks. B. Encourage the client to see, touch, and hold the dead neonate. C. Provide information about possible causes of the stillbirth only if the client requests it. D. Let the nurse is preparing to evaluate a client who gave birth 6 hours ago.

B. Encourage the client to see, touch, and hold the dead neonate.

A postpartum client is scheduled for discharge tomorrow. The nurse is reinforcing discharge instructions with the client. The nurse determines that the client understands the information when stating that she will report which finding to her health care provider? A. episiotomy discomfort B. temperature of 99.2° F (37.3° C) C. whitish vaginal discharge 2 weeks after birth D. redness, warmth, and pain in a breast

D. redness, warmth, and pain in a breast

The nurse is performing a postpartum check on a client. Which nursing action is appropriate? A. Place the client supine position with arms overhead to examine her breasts and fundus. B. Instruct the client to empty her bladder before the examination. C. Wear sterile gloves when assessing the pad and perineum. D. Perform the examination as quickly as possible.

B. Instruct the client to empty her bladder before the examination.

During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? A. It should begin early in the third trimester and end 1 month after delivery. B. It should begin before conception and end 3 months after delivery. C. It should begin when the client learns she's pregnant and end after delivery. D. It should begin at about 5 months' gestation and end at facility discharge.

B. It should begin before conception and end 3 months after delivery.

A 15-year-old client is admitted for treatment of bulimia nervosa. Which intervention is a critical component in the care plan? A. Assessing the client for insomnia B. Monitoring the client for purging behaviors C. Weighing the client daily D. Monitoring the client's vital signs every 2 hours

B. Monitoring the client for purging behaviors

A client with alcohol withdrawal is pulling at the central venous catheter saying "I am swatting the spiders crawling over me." Which intervention is appropriate? A. Encourage the client to rest. B. Protect the client from harm. C. Tell the client there are no spiders. D. Tell the client he is pulling the IV tubing.

B. Protect the client from harm.

The nurse assesses a client who gave birth 4 hours earlier. Which of the following findings would highlight the need for further evaluation? A. Chills B. Scant lochia rubra C. Thirst and fatigue D. Temperature of 100.2° F (37.9° C)

B. Scant lochia rubra

Which of the following correctly defines puerperium? A. The first hour after birth B. The 6 weeks following birth C. The days spent in the hospital D. The duration of breast-feeding

B. The 6 weeks following birth

The nurse is collecting data on a neonate. Which findings should the nurse report to the health care provider? Select all that apply. A. Apgar score of 9 in the first minute of life B. a positive Ortolani sign C. negative Babinski reflex D. birth weight of 3500 g E. head circumference of 42 cm and chest circumference of 35 cm

B. a positive Ortolani sign C. negative Babinski reflex E. head circumference of 42 cm and chest circumference of 35 cm

The nurse is assisting with the development of a care plan for a postpartum client who had an uncomplicated vaginal birth of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum 24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours? A. encouraging high-fiber foods to achieve a soft bowel movement B. encouraging the client to demonstrate an ability to breast-feed the neonate C. administering a rubella vaccination if the client isn't immune D. completing an initial sitz bath

B. encouraging the client to demonstrate an ability to breast-feed the neonate

The nurse is caring for a postpartum client with diabetes who has developed an infection. The nurse would monitor this client for which complication? A. anemia B. ketoacidosis C. respiratory acidosis D. respiratory alkalosis

B. ketoacidosis

Two days after a cesarean birth, a client is diagnosed with deep vein thrombosis. Which complication is this client at greatest risk for? A. hematoma B. pulmonary embolism C. peripheral venous disease D. coronary artery disease

B. pulmonary embolism

A client with chronic alcohol abuse is admitted to the hospital for detoxification. Later that day, the blood pressure increases and the client is given lorazepam to prevent which complication? A. stroke B. seizure C. fainting D. anxiety reaction

B. seizure

A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage? A. hemoglobin level of 12 g/dL B. uterine atony C. thrombophlebitis D. moderate amount of lochia rubra

B. uterine atony

In the fourth stage of labor, a full bladder increases the risk of which postpartum complication? A. Shock B. Disseminated intravascular coagulation (DIC) C. Hemorrhage D. Infection

C. Hemorrhage

The nurse is caring for a 15-year-old client whose parent expresses concern about the client's weight loss and constant dieting. Which client comment requires immediate nursing intervention? A. "I am trying to keep my weight down because it's important to my health as an athlete." B. "I don't like the food my parents cook, so I eat fast food when I go out with friends." C. "I am so fat compared to other kids who are my age." D. "I diet around my monthly periods; otherwise I feel like I get very bloated."

C. "I am so fat compared to other kids who are my age."

A client with anorexia nervosa attended psychoeducational sessions on principles of adequate nutrition. Which statement by the client indicates the education was effective? A. "I should eat while I'm doing things to distract myself." B. "I should eat all my food at night just before I go to bed." C. "I should eat small amounts of food slowly at every meal." D. "I should eat only when I'm with my family and trying to be social."

C. "I should eat small amounts of food slowly at every meal."

Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process? A. Meeting the mother's needs first B. Looking at the infant C. Kissing, embracing, and caring for the infant D. Talking about the baby

C. Kissing, embracing, and caring for the infant

A nurse is determining the need for reinforcement of health education for a female client with anorexia nervosa who lives in a chaotic family situation. Which question is most important for the nurse to ask the client? A. "How many months have your menstrual periods been irregular?" B. "For how often do you think about food in a 24-hour period?" C. "What were the circumstances before your eating disorder?" D. "How much and what kinds of exercise do you engage in every day?"

C. "What were the circumstances before your eating disorder?"

At her follow-up examination, a client who's 6 weeks postpartum tells the nurse that she's exhausted and sore from breast-feeding and wants to formula-feed her baby. She also mentions that she feels like a failure and finds it increasingly difficult "just to get out of bed in the morning." Which intervention should the nurse attempt before notifying the physician? A. Examining the client's breasts to determine areas of breakdown, and discussing proper latch-on technique B. Praising the client for breast-feeding for 6 weeks and encouraging her to "hang-in there" as it takes time to toughen up the nipples C. Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system D. Acknowledging that breast-feeding can be difficult for some mothers, and reassuring the client that she's not a failure just because she wants to use formula

C. Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she wasn't able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and can't stop crying. Which action would be the priority? A. Contact the health care provider to report the client's deteriorating mental status. B. Discuss the client's potential depression with her family members. C. Ask the client to elaborate on her feelings. D. Document the conversation.

C. Ask the client to elaborate on her feelings.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation? A. Contact the client's partner to come home from work and immediately take her to the emergency department. B. Contact the client's physician and the baby's pediatrician. C. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. D. Ask the nursing student to stay with the client while the nurse performs the last home visit in the community.

C. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.

After a 33-year-old male client displays violent behavior, he is placed in restraints. Which intervention by the nurse takes priority for this client? A. Monitoring the client every 2 hours B. Informing the client's case manager that he required restraints C. Continuously monitoring the client D. Assessing the client every 4 hours

C. Continuously monitoring the client

A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands which factor about abuse? A. Open boundaries are common in violent families. B. Violence usually results from a power struggle. C. Domestic violence and abuse span all socioeconomic classes. D. Violent behavior is a genetic trait passed from one generation to the next.

C. Domestic violence and abuse span all socioeconomic classes.

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client? A. Blood glucose level B. Heart rhythm via electrocardiogram (ECG) C. Height of fundus D. Stool test for occult blood

C. Height of fundus

A client while playing chess with a younger client, verbally confronts him for the for lack of attentiveness. Later, the younger client intentionally hides some of the older client's chess pieces. The nurse observes the younger client's actions and recognizes this behavior is a typical example of which disorder? A. Obsessive-compulsive B. Narcissistic C. Passive-aggressive D. Dependent

C. Passive-aggressive

A client with anorexia nervosa tells a nurse about always feeling fat. Which intervention is best for this client? A. Identify negative characteristics to boost self-esteem. B. Encourage the client to honestly evaluate him or herself in a mirror. C. Reinforce education about the dynamics of the disorder. D. Talk about how they are different from peers.

C. Reinforce education about the dynamics of the disorder.

While discussing a client's care with unlicensed assistive personnel (UAP), the nurse detects an odor of alcohol on their breath. Which action should the nurse take? A. Monitor the UAP closely to determine whether performance is impaired. B. Tell the UAP to leave the unit immediately. C. Report observations to the nurse manager. D. Warn the UAP about losing certification.

C. Report observations to the nurse manager.

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? A. Post accolades to the nurse at the nurses' station. B. Send the colleague an anonymous card. C. Share the feedback with the nursing colleague directly. D. It is a breach of confidentiality to share this information with the colleague.

C. Share the feedback with the nursing colleague directly.

Which communication strategy is best to use with a client with anorexia nervosa, who is having problems with peer relationships? A. Use concrete language and maintain a focus on reality. B. Direct the client to talk about what's causing the anxiety. C. Teach the client to communicate feelings and express self appropriately. D. Confront the client about being depressed and self-absorbed.

C. Teach the client to communicate feelings and express self appropriately.

The nurse is collecting data from a parent regarding the child's behavior. Which behavior is consistent with the diagnosis of conduct disorder in this child? A. The child is wetting the bed at night. B. The child has threatened suicide. C. The child has purposely hurt animals. D. The child has a fear of attending school.

C. The child has purposely hurt animals.

A client has just been admitted to the postpartum unit after an uncomplicated vaginal birth. The client is reporting afterpains. Upon reviewing the client medical record, which factor would the nurse identify as most likely playing a role in the client's report? A. The client gave birth at 39 weeks' gestation. B. The client regularly smokes cigarettes. C. The client has given birth five times. D. The client bottle-feeds the neonate.

C. The client has given birth five times.

A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which action would the nurse incorporate to best promote compliance by this client? A. The contract should be written abstractly. B. The contract should be written by the client alone. C. The contract should be written jointly by the client and nurse. D. The contract should be written jointly by the physician and nurse.

C. The contract should be written jointly by the client and nurse.

A family meeting is held with a client who uses alcohol. While listening to the family, which unhealthy communication pattern might be identified? A. use of descriptive jargon B. disapproval of behaviors C. avoidance of issues that cause conflict D. unlimited expression of nonverbal communication

C. avoidance of issues that cause conflict

A client with bulimia nervosa tells a nurse that the major problem is eating too much food in a short period of time and then vomiting. Which short-term goal is most important? A. helping the client understand every person has a satiety level B. discouraging the client to verbalize fears and concerns about food C. determining the amount of food the client will eat without purging D. obtaining a therapy appointment to look at the emotional causes of bulimia nervosa

C. determining the amount of food the client will eat without purging

A nurse is caring for a client with anorexia nervosa who requires a high-protein, high-calorie diet. When offering appropriate choices for snacks, which snack would be best for this client? A. chicken soup and crackers B. a doughnut and orange juice C. egg salad and peanuts D. cashews and strawberries

C. egg salad and peanuts

A nurse is collecting data on a client who was admitted for the treatment of anorexia nervosa. Which symptom does the nurse anticipate finding? Select all that apply. A. tachycardia B. flushed extremities C. hypotension D. coarse, dense hair growth E. dry, cracked skin

C. hypotension E. dry, cracked skin

The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. avoid shopping for large amounts of food. B. control eating impulses. C. identify anxiety-causing situations. D. eat only three meals per day.

C. identify anxiety-causing situations.

A client is admitted to a medical-surgical unit for treatment of an orthopedic injury. In addition to this admitting diagnosis, the nurse notes that the client has a history of borderline personality disorder with episodes of cutting/self- mutilation. Which type of behavior would the nurse expect to be present due to this self-mutilation history? (Select all that apply.) A. no presence of cuts or burns found during assessment B. no unexplained frequent injuries C. knife or razor in purse or bag D. insistence on wearing long-sleeved shirt even in warm temperatures E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing

C. knife or razor in purse or bag D. insistence on wearing long-sleeved shirt even in warm temperatures E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition? A. chest pain B. breast engorgement C. orthostatic hypotension D. separation of episiotomy incision

C. orthostatic hypotension

A nurse is talking to the family of a client with anorexia nervosa. Which family behavior is most likely to be seen during the family's interaction? A. sibling rivalry B. rage reactions C. parental disagreement D. excessive independence

C. parental disagreement

A 16-year-old female was admitted to the hospital for treatment of anorexia nervosa. A nurse is teaching the client's mother about the disease process. The nurse recognizes that the teaching was effective when the mother states that anorexia nervosa is characterized by: A. weight loss of more than 10 lb (4.5 kg) in 6 months. B. uncontrolled food consumption over a short time. C. refusal to maintain normal body weight. D. anxiety-related habits.

C. refusal to maintain normal body weight.

A nurse is assisting with the development of a plan of care for a client with anorexia nervosa. Which action would the nurse expect to implement as part of the plan? A. restricting family visits until the client begins to eat B. providing client privacy during meals C. reinforcing a strict refeeding plan for the client D. encouraging the client to exercise vigorously

C. reinforcing a strict refeeding plan for the client

The nurse is caring for a client with bulimia nervosa. Which observation by the nurse is life-threatening and should be reported to the health care provider immediately? A. serum calcium 10.1 mg/dL B. heart rate 56 beats/minute C. serum potassium 2.9 m Eq/L D. respiratory rate 16 breaths/minute

C. serum potassium 2.9 m Eq/L

The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? A. "Client will state that she may attempt another pregnancy after 3 months of follow-up care." B. "Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge." C. "Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises." D. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

D. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

The nurse is teaching a client about oral contraceptive therapy. The client reports missing three doses of the scheduled medication. Which statement made by the client indicates understanding of the teaching regarding oral contraceptives? A. "If I miss any doses, I will take all the missed doses as soon as I notice the oversight." B. "I will take two pills for the next 2 days and use an alternative contraceptive method until the next cycle." C. "I will take three pills for the next 3 days and use an alternative contraceptive method until the next cycle." D. "I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."

D. "I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."

A client recovering from alcohol addiction asks a nurse how to talk to his or her children about the impact of addiction on them. Which response by the nurse is most appropriate? A. "Try to limit references to the addiction and focus on the present." B. "Talk about all the hardships you've had in working to remain sober." C. "Tell them you're sorry and emphasize that you're doing so much better now." D. "Talk to them by acknowledging the difficulties and pain your drinking caused."

D. "Talk to them by acknowledging the difficulties and pain your drinking caused."

The mother of a neonate expresses concern about how she will continue to breastfeed when she returns to work in 6 weeks. Which response by the nurse would be best? A. "At least you will have breastfed for 6 weeks." B. "One or two bottles a day is fine." C. "Why do you think you have to stop when you go back?" D. "Tell me what you would like to do when you return to work."

D. "Tell me what you would like to do when you return to work."

A nurse is helping to prepare a client for discharge following the vaginal birth of a healthy neonate. As part of the discharge plan, the nurse is reviewing how to perform Kegel exercises. Which statement by the client indicates that additional teaching is needed? A. "I will perform the exercises several times daily." B. "Kegel exercises can be performed sitting or standing." C. "I can practice by trying to stop my stream of urine." D. "The exercise strengthens the gluteal muscles."

D. "The exercise strengthens the gluteal muscles."

During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on his forearms. What is the most appropriate way for the nurse to respond? A. "That's it! You're on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse's interaction with the client, which is the nurse's best response? A. "Using drugs jeopardizes your health and you should consider quitting." B. "If tested, you will lose your job." C. "You could easily have an error in judgement and cause a serious accident." D. "There's a problem with you choosing to use drugs as a way to cope with the stressors you experience."

D. "There's a problem with you choosing to use drugs as a way to cope with the stressors you experience."

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom? A. Pain in the pelvic area B. Increased blood pressure C. Urine retention D. Sudden onset of shortness of breath

D. Sudden onset of shortness of breath

The mother of a client with bulimia nervosa asks a nurse if bulimia nervosa will stop her daughter from menstruating. Which response is best? A. "All women with anorexia nervosa or bulimia nervosa will have amenorrhea." B. "When your daughter is bingeing and purging, she won't have normal periods." C. "The eating disorder must be ongoing for your daughter's menstrual cycle to change." D. "Your daughter may have a normal or abnormal menstrual cycle, depending on the severity of her problem."

D. "Your daughter may have a normal or abnormal menstrual cycle, depending on the severity of her problem."

A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. Which of the following approaches should the nurse initially utilize? A. Enter the room quietly and move beside her to assess her injuries. B. Call for staff back-up before entering the room and restraining her. C. Move as much glass away from her as possible and sit next to her quietly. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority? A. Vigorously massage the fundus. B. Immediately call the health care provider. C. Have the charge nurse review the finding. D. Ask the client when she last changed her perineal pad.

D. Ask the client when she last changed her perineal pad.

A postpartum client who has developed mastitis is being discharged. What recommendation would be most appropriate when the client voices concern about breast-feeding her neonate with this condition? A. Stop breast-feeding until completing the antibiotic. B. Supplement feeding with formula until the infection resolves. C. Don't use analgesics because they aren't compatible with breast-feeding. D. Continue to breast-feed; mastitis won't infect the neonate.

D. Continue to breast-feed; mastitis won't infect the neonate.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? A. Talking with the client's family about his angry feelings B. Performing an assessment for tardive dyskinesia C. Learning to effectively express needs to staff and others D. Demonstrating control over aggressive behavior

D. Demonstrating control over aggressive behavior

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? A. Explain that the unit is short staffed and that the nurses are doing the best they can. B. Call the nurse manager to speak with the couple. C. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit. D. Encourage the family to identify their frustrations and fears.

D. Encourage the family to identify their frustrations and fears.

A nurse is preparing to evaluate a client who gave birth 6 hours ago. Which statement best explains the use of gloves during the postpartum evaluation? A. Gloves act as a barrier for the client against infectious organisms. B. Gloves provide a barrier for the nurse against infectious organisms. C. Gloves protect the client from the nurse's cold hands. D. Gloves are an essential part of standard precautions.

D. Gloves are an essential part of standard precautions.

A student nurse is accompanying a community health nurse for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The mother's partner declines this opportunity. What is the nurse's most appropriate response? A. Reassure the partner that the student nurse will be professional. B. Ask the partner to leave the premises. C. Ask the partner about any concerns. D. Honor the partner's preference.

D. Honor the partner's preference.

The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety? A. Identifying and confronting suspicious-looking visitors B. Encouraging the parents to room-in with the infant C. Keeping security cameras and alarms activated at all times D. Instructing the mother to notify staff when she showers to avoid leaving the infant unattended

D. Instructing the mother to notify staff when she showers to avoid leaving the infant unattended

A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9 months. The health care team recommends rehabilitative treatment for this client. Why was this treatment recommended? A. It's the only option for controlling alcohol consumption. B. It helps the client identify a new group of friends. C. It helps the client understand the effects of alcohol on his body. D. It helps the client identify the relationship between his problems and alcohol consumption.

D. It helps the client identify the relationship between his problems and alcohol consumption.

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate? A. Mothers with diabetes who breast-feed have a hard time controlling their insulin needs. B. Mothers with diabetes shouldn't breast-feed because of potential complications. C. Mothers with diabetes shouldn't breast-feed; insulin requirements usually are doubled. D. Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

D. Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

A 33-year-old male client on a psychiatric unit throws a chair at a staff member and shouts, "If any of you come close to me, I'll make sure that you never walk again." What is the nurse's first priority? A. Talking with the client to see if he'll calm down B. Calling the physician to obtain an order for restraints C. Instructing all staff members to stay away from the client D. Placing the client in restraints with the assistance of other staff members who are specially trained in restraint application

D. Placing the client in restraints with the assistance of other staff members who are specially trained in restraint application

A client who experienced alcohol withdrawal is no longer having hallucinations or tremors and states, "I would like to enter a rehabilitation facility to stop drinking." Which intervention is appropriate? A. Ask about insurance. B. Have the client discuss this with family members. C. Refer the client to Alcoholics Anonymous (AA). D. Promote participation in a treatment program.

D. Promote participation in a treatment program.

A nurse is working with a client with anorexia nervosa who has acrocyanosis in the extremities. Which short-term goal is most important for the client? A. Do daily range-of-motion exercises. B. Eat some fatty foods daily. C. Check neurologic reflexes. D. Promote systemic circulation.

D. Promote systemic circulation.

A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which nursing strategy should the nurse use when dealing with this client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client's weight and attractiveness.

D. Provide objective data and feedback regarding the client's weight and attractiveness.

While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best? A. Inform the couple that successful reversal is unlikely. B. Report the conversation to the health care provider. C. Complete the perioperative checklist. D. Review the client's understanding of the procedure in private.

D. Review the client's understanding of the procedure in private.

The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize? A. The most common pathogen is group A beta-hemolytic streptococci. B. A breast abscess is a common complication of mastitis. C. Mastitis usually develops in both breasts of a breast-feeding client. D. Symptoms include fever, chills, malaise, and localized breast tenderness.

D. Symptoms include fever, chills, malaise, and localized breast tenderness.

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention? A. The baby's mouth covers the nipple and 2 to 3 cm of the areolar radius. B. The baby's nose, cheeks, and chin are touching the breast. C. The baby swallows audibly. D. The baby's lips smack.

D. The baby's lips smack.

The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains? A. The client delivered at 39 weeks' gestation. B. The client smokes cigarettes. C. The client has decided to bottle-feed her neonate. D. The client is a gravida 6, para 5.

D. The client is a gravida 6, para 5.

A client had an emergency cesarean birth. Afterward, the client expresses disappointment about not being able to give birth vaginally. The nurse understands that this feeling may be based on which concept? A. Cesarean births have a longer recovery time. B. Depression is more common after a cesarean birth. C. There is more fatigue after a cesarean birth. D. The client may feel a loss for not having experienced a vaginal birth.

D. The client may feel a loss for not having experienced a vaginal birth.

The nurse is checking for rooting reflex in a newborn. Which response should the nurse expect to see? A. The neonate will turn head to the side when lying on his or her back. B. The neonate will abduct the arms and extend them. C. The neonate will curl fingers around another person's fingers. D. The neonate will turn the head to the side of the stroked cheek.

D. The neonate will turn the head to the side of the stroked cheek.

As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make? A. The client's behavior represents signs of postpartum depression. B. The client is acting abnormally and her physician needs to be notified. C. A home assessment is necessary to assure the well-being of the mother and the baby. D. This is expected behavior for a client 3 to 7 days postpartum.

D. This is expected behavior for a client 3 to 7 days postpartum.

A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery? A. Delay breast-feeding until 24 hours after delivery. B. Have the mother breast-feed frequently during the day and every 4 to 6 hours at night. C. Use the cradle hold position to avoid incisional discomfort. D. Use the football hold to avoid incisional discomfort.

D. Use the football hold to avoid incisional discomfort.

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? A. affixing matching identification bands to the parents and neonate at birth B. positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway C. affixing a security bracelet that monitors movement to a neonate D. allowing volunteers to return neonates to the nursery

D. allowing volunteers to return neonates to the nursery

A primigravida client experiences a normal vaginal birth. The next day, the nurse monitors the client's lochia for color, amount, and the presence of clots. Which finding best describes lochia on the first postpartum day? A. bright red, large amount, with many clots B. pink, moderate amount, with no clots C. white, scant amount, with no clots D. dark red, moderate amount, with a few small clots

D. dark red, moderate amount, with a few small clots

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to: A. check the client's medical record for an order for an as-needed dose of medication for agitation. B. place the client in full leather restraints. C. call the physician and report the behavior. D. remove all other clients from the day room.

D. remove all other clients from the day room.

Which finding does the nurse recognize is commonly associated with use of alcohol in a young, depressed adult woman? A. defiant responses B. infertility C. memory loss D. sexual abuse

D. sexual abuse

A client is admitted to a long-term care facility with a diagnosis of organic mental disorder. When assisting with the plan of care, which approach would best to help meet the client's needs? A. making sure that the client completes tasks B. giving the client alternative choices in making decisions C. maintaining a gentle approach that does not set limits D. simplifying the environment as much as possible

D. simplifying the environment as much as possible

The nurse is caring for a client with a history of cocaine abuse. Which test might be ordered following a return to an inpatient treatment facility? A. antibody screen B. glucose screen C. hepatic screen D. urine screen

D. urine screen

The nurse is reviewing the medical record of a client who is 6 weeks postpartum and came for a follow up appointment with her health care provider. The client's uterus is enlarged and soft, and she is experiencing vaginal bleeding. Based on the findings, which condition would the nurse most likely suspect? A. cervical laceration B. clotting deficiency C. perineal laceration D. uterine subinvolution

D. uterine subinvolution

Which outcome developed by the health care team is appropriate for a client diagnosed with pedophilia? A. attending all meetings on the unit B. using triggers to initiate sexual behaviors C. informing the client's employer of the reason for hospitalization D. verbalizing appropriate methods to meet sexual needs upon discharge

D. verbalizing appropriate methods to meet sexual needs upon discharge

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she: A. express milk manually. B. take antilactation drugs. C. take hot showers. D. wear a supportive, well-fitting brassiere.

D. wear a supportive, well-fitting brassiere.

Which statement from a client with bulimia shows that the client understands the concept of relapse? A. "If I can maintain control, I'll have problems." B. "If I have problems, then I haven't learned much." C. "If this illness becomes chronic, I won't be able to handle it." D.. "If I have problems, I can start over again and not feel hopeless."

D.. "If I have problems, I can start over again and not feel hopeless."