Psych EXAM 2 (ch 9-14)
21. A client in a busy inpatient psychiatric unit is noisy and combative. The nurse determines that the best course of action for all involved is to seclude the client until they are able to regain control of his behavior. On which ethical principle did the nurse base this decision? A. Utilitarianism B. Deontology C. Nonmaleficence D. Veracity
A
24. A client is struggling to make a decision about having an abortion since their spouse left them. The client has two children to care for and asks the nurse what they should do. Which action by the nurse is a priority? A. The nurse should examine their own values and beliefs first. B. The nurse should advise the client to make a decision without input from others. C. Encourage the client to talk with their religious leader about what to do. D. Refer the client to a facility that performs abortions on an outpatient basis.
A
11. The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate? A. Accept the client's decision and continue to maintain safety. B. Obtain a discharge order for nonadherence to the medication regimen. C. Inform the client to refuse the medication means not getting any better. D. Restrain the client and give the medication intramuscularly.
A
13. A client approaches the nurse and loudly states, ìI'm not putting up with this anymore!î The most appropriate response by the nurse would be which of the following? A) I can see you are angry. Tell me what's going on. B) You are not allowed to make threats. Please keep your voice down. C) Why do you say that? D) You are here voluntarily. You can leave if you want.
A
14. A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on appropriate use of seclusion? A. Autonomy B. Beneficence C. Justice D. Veracity
A
16. An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following? A) Call for an emergency response from trained personnel. B) Approach the client and firmly say, ìStop, put it down.î C) Calmly call the client by name and encourage verbal expression of anger. D) Assist the client to use problem-solving techniques instead of aggression.
A
19. When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first? A) Call for assistance. B) Give the client choices. C) Remove the other clients. D) Talk to the client calmly.
A
24. The nurse is creating a plan of care for a grieving client. Which outcome will the nurse establish that will be most beneficial? A. The client will develop a plan for coping with the loss. B. The client will demonstrate self-reliance during the grief process. C. The client will suppress emotions related to the loss. D. The client will verbalize that loss will not adversely affect the quality of life.
A
25. A client with depression is found to have attempted suicide in the bathroom and sustains injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against? A. Malpractice B. Battery C. Assault D. False imprisonment
A
28. A nurse is reviewing an electronic medical record to determine if a client's rights have been violated by another member of the health care team. Which finding will the nurse identify that would indicate a violation of the client rights? A. There is no documentation of benefits of treatment or treatment options. B. The client's belongings are searched at admission. C. Physical restraints were used to prevent harm to self and others. D. The client was placed on one-to-one continuous observation for threats of self- harm.
A
30. Oneofthefirststepsthatanurseshouldtaketodealeffectivelywithaggressive clients is which of the following? A) Reflect on abilities to handle own feelings of anger B) Learn professional skills of anger management C) Become proficient using reflective communication techniques D) Understand how to activate crisis response teams
A
4. The nurse is caring for a group of clients in the mental health clinic. Which client is most likely to be mandated for outpatient treatment? A. A client addicted to alcohol who has two driving under the influence offenses B. A client with schizophrenia living in a single-family home with siblings C. A client with bipolar disorder quit three jobs in the last 6 months D. A homeless client arrested for petty theft of groceries from a convenience store.
A
6. The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior? A. "Let's go to a quiet area and talk about what is upsetting you." B. "I don't know what set you off today but you have to get along with others." C. "You have to take this medication to settle you down and stop your behavior." D. "If your behavior continues, we have no choice but to place you in seclusion."
A
7. The nurse working in an addictive disorders' unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which is the appropriate response by the nurse to the caller? A. "I cannot confirm or deny the existence of any client here." B. "You will need to be placed on the client's contact list before I can discuss any information with you." C. "The person you are asking for is not a client here." D. "Hold one minute while I get the client for you."
A
Friends of two teenagers recently killed in a car accident are discussing their sense of loss. Which comment best indicates that the friends are trying to make sense of the loss cognitively? A. "Why did they have to die so young?" B. "They shouldn't have been driving so recklessly." C. "If we had only stayed longer, they would not have been on that road." D. "It took the ambulance too long to get there."
A
23. The nurse is working in a state psychiatric facility and encounters situations which require the evaluation of ethical dilemmas. Which dilemmas involve the ethical principle of fidelity? Select all that apply. A. The nurse is unable to agree with the policies or common practices of an agency. B. The nurse is faced with a decision to violate a policy that is harmful to the client. C. The nurse is certain that clients of different racial and ethnic backgrounds are treated the same as other clients. D. The nurse identifies a combative client must be secluded against their will to prevent harm to others. E. The client refuses to take medication and the nurse respects the client's right to refuse medication.
A,B
10. The bereaved client has worked through many processes of grief with the nurse. Which are eventual outcomes of the emotional dimension of grieving? Select all that apply. A. The survivor begins to reestablish a sense of personal identity, direction, and purpose for living. B. The survivor begins to gain independence and confidence. C. The survivor develops new ways of managing life and new relationships. D. The survivor's life returns to the same state as it was before the loss. E. The survivor forgets about the loss.
A,B,C
26. Which of the following interventions are most effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. A) Planning group activities such as playing games B) Scheduling one-to-one interactions with the client C) Providing structure and consistency in the unit D) Avoiding discussions among clients on the unit E) Discouraging clients from negotiating solutions
A,B,C
4. Which of the following are common characteristics of violent families regardless of the type of abuse that exists? Select all that apply. A) Abuse of power and control B) Alcohol and other drug abuse C) Intergenerational transmission D) Social isolation E) Victim instigates
A,B,C,D
5. The nurse is caring for several clients in the inpatient behavioral health unit. Which client(s) does the nurse identify will require someone to make decisions regarding their medical and psychiatric care in their best interest? Select all that apply. A. A client that is gravely disabled B. A client with severe intellectual developmental disorder C. A client that is nonadherent to their medication regimen D. A client that is unable to provide basic needs when resources exist E. A client that acts only on their own interests
A,B,D
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder
A,B,D
18. A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. A. The spouse of a person who died 7 years ago and visits the grave several times a day B. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day C. A driver whose spouse and children all died as a result of his driving drunk D. An adult who insisted for many years that the adult hated the adult's deceased parentE. The parent of a child who died after the having left the child in a car on a hot day
A,C,D,E
12. The nurse is caring for a client whose death is imminent and receiving home hospice care. In preparing the family members for the imminent death of their loved one, how will the hospice nurse assist the family in the grieving process? Select all that apply. A. Dealing with the shock of losing a loved one B. Burial plans after death has occurred C. Efforts to stay connected to the client after death D. Use of support from family and friends E. Anger at the loss of a loved one
A,C,E
17. The nurse is considering the use of short-term restraints for a client. Which criteria will the nurse use to determine if the client meets the use of instituting the short-term use of restraint or seclusion? Select all that apply. A. The client is aggressive. B. The client requires punitive action for behavior. C. The client is imminently dangerous to the self or to others. D. The client is physically and emotionally self-controlled. E. All other means of calming the client have been unsuccessful.
A,C,E
2. The nurse is evaluating clients in the emergency department (ED) for pending mental-health admissions. Which client will be admitted for involuntary hospitalization? Select all that apply. A. A client who states they intend to commit suicide and is making a plan B. A client who does not bathe regularly or change clothes often C. A client who states they intend to harm others by a deliberate act D. A client who has diabetes who refuses to follow the prescribed diet E. A client who is unable to control rage and is assaulting others
A,C,E
1. The nurse is collecting assessment data on a client who is suspected to be a victim of violence. Which assessment data would support the suspicion that the client is a victim of abuse? Select all that apply. A) The client has few friends. B) The client holds a dominant role in the family. C) The client is in charge of the family finances. D) There is a moderate amount of alcohol use in the home. E) The client reports that the father was abusive during childhood.
A,D,E
32. Whichofthefollowingareimportantissuesfornursestobeawareofwhen working with angry, hostile, or aggressive clients? Select all that apply. A) Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution. B) Nurses must not allow themselves to become angry under any circumstances. C) Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse. D) Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.
A,D,E
22. The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? A) Client's mood B) Client's safety C) Court order D) Physician's order
B
24. Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others
B
21. The client identifies anger management as a problem. What is the next step in planning therapeutic interactions? A) Give the client a variety of choices on how to express anger. B) Give the client permission to be angry. C) Point out the senselessness of anger. D) Tell the client not to be angry all the
B
26. A nurse in the emergency department is planning for a client with mental illness to be placed in an inpatient hospitalization. Which is a criterion assessed by the nurse is condition of this type of admission? A. Nonadherence with medication administration at home B. Presents a clear danger to self or others C. Develops new symptoms of the illness D. Has no support systems in the community
B
1. A client states to their parents, "I am going to hurt you if you come too close to me!" The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. Which statement made by the nurse identifies the clients' rights that will be retained during this admission? Select all that apply. A. "We will not be discussing your admission with anyone other than health care personnel involved in your care." B. "You will be able to leave the facility whenever you feel that you are in control and your parents come and get you." C. "Your treatment plan will be reviewed regularly and changes will be made accordingly for the best outcomes." D. "If you don't want to take your medication, we are not able to force you to take it while you are here." E. "I understand that you want to write a letter to your parents and apologize but you cannot do this while hospitalized."
Answer: A, C, D
1. A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings? A. Inform the client that since it is too late to change, acceptance is inevitable. B. Be an active listener and use silence to facilitate communication. C. Refer the client to the chaplain for religious counseling. D. Ask the client if they are in denial regarding the seriousness of their illness.
B
10. A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse? A. The client is entitled to have a relationship with anyone and the nurse should ignore the behavior. B. In order to protect the rights of the client, the nurse should report the behavior to the supervisor. C. The nurse should confront the nurse and tell them the behavior must immediately stop. D. Discuss this with the client and tell them they are being emotionally manipulated.
B
10. The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting? A) Triggering B) Escalation C) Crisis D) Recovery
B
11. The nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize which of the following? A) Decreased problem-solving ability B) Restlessness and irritability C) Remorse D) Severe muscle tension
B
12. A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client? A. The nurse pushes the client, and the client falls to the floor and sustains a nosebleed. B. The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth. C. The nurse throws the medication in the trash and documents the client refuses the medication. D. The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist.
B
22. A client with end-stage pancreatic cancer asks the nurse, "Am I going to die from this?" Which response by the nurse is demonstrative of veracity? A. "We all will die at some time, some earlier than others." B. "You have a terminal illness that will take your life at some point." C. "We will take care of you and try and keep you comfortable." D. "Why do you think you will die from this disease?"
B
13. The nurse is working in a behavioral health unit with a variety of clients with mental health disorders. Which client does the nurse identify will require the nurse and the health care team to warn a third party? A. A client with paranoid schizophrenia states, "Those aliens are sending messages through my brain, and I have to protect myself." B. A client that states, "When I get out of here, I have a plan to kill that judge that sentenced me here. I am going to blow their house up." C. A client states to the nurse, "My spouse is so annoying, I just want to kill them sometimes." D. A client that states, "Sometimes I get so angry that I could just end everyone and be alone in the world."
B
15. A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence? A. Explaining the behavioral requirements for release of restraint to the client B. Assuring that the restraints are not causing injury to the client C. Applying restraints based solely on assessment findings and not on attitude toward the client D. Releasing the client when stated behavioral control is achieved
B
15. Inthepsychiatricsetting,whatisthemosteffectiveinterventioninpreventing the hostile client's behavior from escalating to physical aggression? A) Getting as far away from him or her as possible B) Engaging the hostile person in dialogue C) Yelling at the client to settle down now D) Ensuring that the client gets his or her
B
16. An adult client is put in restraints after all other attempts to reduce aggression have failed. Which action by the nurse is required now that restraints have been instituted? A. Review of the appropriateness of restraints every 8 hours B. A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint C. A documented nursing assessment every 4 hours D. Constant one-on-one supervision during the first hour and then video monitoring
B
18. The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance
B
19. A malpractice lawsuit was filed after a nurse restrained a client for screaming at and attempting to strike anyone who was within striking distance. The nurse followed agency procedures that were consistent with Joint Commission Standards. For which reason is this malpractice lawsuit most likely to be unsuccessful? A. The nurse did not have a duty. B. The nurse did not breach duty. C. The client did not suffer some type of loss, damage, or injury. D. There was no evidence that a breach of duty was a direct cause of the loss, damage, or injury.
B
19. The nurse is having an initial counseling session with a client that had a spontaneous abortion at 28-weeks' gestation. After establishing rapport, which is the priority nursing intervention? A. Assessing the client's support system B. Exploring what this loss means for the client C. Discussing helpful ways to cope with the loss D. Assessing what knowledge the client desires about the situation
B
29. The nurse is working on the behavioral health unit caring for several clients. Which client situation indicates that the client is being falsely imprisoned? A. A client is confused, combative, and insists they will not be stopped from leaving. The nurse restrains the client and then seeks the order. B. When the client exhibits attention seeking behaviors, the nurse informs the client they will have to stay in their room or be restrained. C. A client with psychosis attempts to leave the unit, and the nurse escorts the client back to the unit. D. An involuntarily admitted client is brought back to the unit by security when locking themselves in the bathroom.
B
31. A client is scheduled for a mastectomy for breast cancer. The client is quiet, shows little emotion, and states that they have no questions. Which priority assessment will the nurse perform for this client? A. The client's plans for reconstructive surgery B. What the mastectomy means to the client C. Whether the client completely understands the surgery D. Why the client seems depressed
B
32. A client states to a nurse, "They found a lump in my neck, and now they tell me I have an incurable disease." The client is young and appears to find this information hard to believe. Which pattern of response does the client's statement reflect? A. Restitution B. Shock and disbelief C. Physiologic grieving D. Recovery
B
33. After the death of a client's spouse, the client tells the nurse, "I can never live without my spouse. They were my whole life." Which is the most therapeutic response from the nurse? A. "Remember, your spouse is no longer suffering." B. "Your spouse's death is a terrible loss for you." C. "Each day will get a little better." D. "Your friends will help you cope with this."
B
9. A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggressing cycle? A) Triggering B) Escalation C) Crisis D) Recovery
B
A young female immigrant presents in the rural health clinic with facial bruising and a fractured nose. The client is reluctant to give details of the nature of her injuries. Which of the following should be a consideration in providing care for this client? A) Most views regarding domestic violence are universal across cultures. B) She may fear deportation if she seeks public assistance. C) Immigrants have expedited access to public legal services. D) The nurse should ignore the details and focus on treatment.
B
The nurse is conducting a history and physical exam on a client who is grieving the unwanted loss of a marriage by divorce. Which subjective physical symptom of grief would the nurse most likely assess when performing the assessment? A. Hair loss B. Insomnia C. Compulsive behaviors D. Vomiting
B
Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects
B
Which of the following is the best explanation for why family violence tends to occur over multiple generations of families? A) A tendency toward violence is hereditary. B) Family violence may be perpetuated between generations of families by role modeling and social learning. C) All persons who have become victims of family violence will grow up to perpetrate family violence. D) Family violence does not tend to have an intergenerational transmission process.
B
Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? A) Delusions B) Depression C) Dementia D) Delirium
B
16. The nurse is leading a support group for clients at the outpatient clinic that have experienced a loss. Which clients are most likely to experience disenfranchised grief? Select all that apply. A. A young adult whose spouse has just died suddenly B. A family whose long-time pet snake has just died C. A nurse who has just witnessed the death of a client D. A couple who has just experienced pregnancy loss E. The partner of a client who just died from AIDS
B,C,D,E
20. The nurse is assessing a client that is newly grieving a life partner. Which are critical components for the nurse to assess in this client? Select all that apply. A. Genetic risk B. Perception of the loss C. Support system D. Coping behaviors E. Spiritual and religious
B,C,D,E
13. The nurse is providing care to a client experiencing bereavement after the death of a family member. Which action is most effective in order to provide the most culturally competent care? A. Understand the practices associated with a client's culture. B. Suggest developing a new ritual to make mourning meaningful. C. Ask the client which rituals are personally meaningful. D. Contact a spiritual leader from the client's culture to become involved.
C
14. A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time? A) Clear others out of the immediate area. B) Prepare a PRN sedative. C) Tell the client to stop and take a time-out. D) Alert the security department of an impending aggressive outbu
C
17. A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.
C
17. The nurse is caring for a client who was recently in a motor vehicle accident and paralyzed from a T6 spinal cord fracture. Which is most likely to prevent the client from experiencing complicated grief? A. The client's tendency to suppress emotions B. A history of depression treated with medication C. The client places trust in people familiar to them. D. The client is dependent on others to meet their needs.
C
20. The client with a history of explosive outbursts becomes angry and states, ìI am really getting angry.î The nurse sees this as A) controlling. B) manipulation. C) progress. D) regression.
C
22. A young client tells the nurse that the client's spouse died 3 months ago, and the client is feeling alone and vulnerable. Which statement indicates that the client's coping skills are adequate? A. "I can't understand why this happened to me." B. "I'm mentally healthy. I can solve my own problems." C. "I will find a support group to help me through this." D. "What can I do? My spouse abandoned me."
C
25. The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation? A. "I'm sorry you are sad. Is there anything I can do to help you feel better?" B. "Please don't cry. It will get better." C. "You look very sad. What is happening?" D. "I know you are upset but things will look better tomorrow"
C
27. An older adult client living alone after the death of a spouse is having difficulty maintaining the home. The client states to the nurse, "I don't need help. I've been managing for years." Which response helps the client shift from denial to consciously coping with the situation? A. "You don't think you need any help? But your family is worried about you." B. "It must be hard to lose your independence. I'll ask a social worker to see what can be arranged." C. "If you were to need help with your house, who might you ask for help?" D. "If you don't ask for some help then the only option is to move to an assisted living facility."
C
28. Afteranangryoutburst,aclientquicklyappearsmorecalmandrational.Thenurse approaches the client. Which of the following is the most helpful response to the client at this time? A) We will have to talk about this later. B) You really scared me. I'm glad you are okay. C) What happened that got you so upset? D) What can you do differently next time you get angry?
C
29. A client comes to the health care provider's office for an annual checkup. During the interview, the client informs the nurse that the spouse died unexpectedly of a heart attack 2 months ago. Which is the most appropriate response by the nurse? A. "At least you and your spouse enjoyed life right until the end." B. "It's better to go quickly like your spouse did instead of suffering." C. "The loss of your spouse must be very painful for you." D. "You'll feel better after you get over the shock of your spouse's death."
C
3. A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and killing themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice? A. Call security and ask them to detain the client from leaving B. Allow the client to leave with a referral to community resources for follow-up care C. Contact the psychiatrist for initiation of commitment proceedings D. Contact the client's family to request they convince the client to stay
C
3. A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively? A) I really wish you would stop nagging me. B) You are not perfect either. C) I feel unappreciated when you criticize me. D) Are you telling me you want me to change?
C
3. A young adult client is scheduled for a hysterectomy and states to the nurse, "I don't know why I'm so upset about it, it's not like I am going to have more children." Which is the most therapeutic response by the nurse? A. "I had a hysterectomy when I was about your age and felt so much better after it." B. "If you think about it logically, it really is just like getting your appendix taken out." C. "Your feelings are valid. Let's talk about your feelings about having the surgery and what bothers you most." D. "You'll do fine during your surgery because you have one of the best surgeons performing the procedure."
C
33. What a culture considers acceptable strongly influences the expression of anger.Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects? A) Hwa-Byung B) Hwabyeong C) Amok D) BouffÈe
C
35. A nurse cared for a terminally ill client over a month and developed a therapeutic nurse-client relationship. After the client's death, feelings of sadness, sleeping poorly, and feeling mildly depressed were experienced by the nurse. Which is the best action to improve resolution of grief? A. The nurse needs to use stress reduction strategies. B. The nurse needs to seek therapy for dysfunctional grief. C. The nurse and should seek an informal forum for discussing death. D. The nurse needs to consider taking a leave of absence to pursue healing.
C
4. A client has just been informed of a diagnosis of terminal cancer. The client states, "God has to have mercy on me because my children need me. God knows I'll change if I get through this." The nurse documents that the client is expressing signs of which of Kübler-Ross's stages of grief? A. Denial B. Anger C. Bargaining D. Depression
C
6. The client with terminal lung cancer says to the nurse, "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing? A. Acceptance B. Anger C. Bargaining D. Depression
C
Atwhichpointinthestagesofaggressiveincidentsisinterventionleastlikelyto be effective in preventing physically aggressive behavior? A) Triggering B) Escalation C) Crisis D) Postcrisis
C
The nurse is preparing a client that has been in the behavioral health unit with depression from the loss of a family member for discharge. The client states to the nurse, "I just didn't care before about eating or doing anything to care for myself." Which is the best response by the nurse? A. "You probably won't feel like doing much for the next few weeks while you are on this depression medication." B. "You have done so well why you have been here that I would hate to see you slip into old patterns." C. "It's important for you to eat a nutritious diet, hydrate, and exercise to help relieve stress and tension." D. "It is time that you get out and meet new people and start enjoying your life. Life is too short."
C
The nurse is working with a client who experienced their youngest child's death 2 months ago. When the nurse approaches, the client yells, "I don't want to talk to you. You have no idea what it's like to lose a child!" Which response is most therapeutic to the client? A. "Please lower your voice and speak to me respectfully." B. "I understand exactly what you are going through right now." C. "I would like to sit with you. We don't need to talk right now." D. "I will leave so you don't have to talk to me if you don't want to."
C
12. A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse? A) I can see that you need attention; you should calmly ask for what you want. B) I don't want to hear that kind of language; don't ever do that again. C) I will limit your smoking privileges if you can't control yourself. D) You seem angry. Tell me more about how you're feeling.
D
14. A nurse has been caring for a gunshot victim who has just died. Various family and friends are present. One of the visitors privately discloses to the nurse that the visitor and the client were having an affair. Which is the best action by the nurse after learning of this relationship? A. Give the name of a clergy to the visitor and suggest the visitor contact the person for support. B. Encourage the visitor to ask for support from the friends who are present. C. Ignore the information about the affair and tend to the family. D. Privately offer support to the visitor who was having the affair with the client.
D
15. A client has just had an elective abortion to end an unintended pregnancy. Afterward, the client cries because although they wanted to have children in future years, this pregnancy was not well timed. Which type of grief is this client most likely to experience? A. Anticipatory grief B. Absence of grief C. Complicated grief D. Disenfranchised grief
D
18. The client feels that their rights have been violated when being placed in restraints after an incident involving a physical altercation with another client. Which action by the nurse is violating the client's rights? A. The right to receive confidential and respectful care B. The right to provide informed consent C. The right to be treated in a timely manner D. The right to receive treatment in the least restrictive environment
D
2. The nurse is meeting with a client that is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, which will the nurse do prior to the meeting? A. The nurse will evaluate previous methods of interventions that were beneficial. B. The nurse will share personal information for the client related to the loss experienced by the nurse. C. The nurse will establish the goals for the process and present to the client. D. The nurse should examine their personal attitudes related to loss and grieving.
D
20. The client is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Ensuring that the client has provided informed consent for a treatment regimen displays which ethical principle? A. Fidelity B. Nonmaleficence C. Justice D. Autonomy
D
21. The nurse is talking with a client that has been feeling depressed lately. Which situation that the client is experiencing indicates that the client is feeling a loss of self-esteem? A. The client is having an amputation of the left leg due to diabetes. B. The client realizes that they will never be able to have a child. C. The client is the survivor of a mass shooting in a synagogue. D. The client is fired from a job they had worked at for over 25 years.
D
23. A couple comes to the emergency department with their 5-month-old child that is not breathing or with a pulse. After resuscitation efforts, the child dies in the emergency department (ED) with the parents in attendance. Which action by the parents will help with the grieving process? A. Postpone notification to the extended family. B. Delay expressing grief until ready to cope. C. Minimize discussion of the death with others. D. Plan funeral arrangements for the child.
D
23. The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse? A) Take an authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what is going on. D) Engage the attention of the client who is still yelling and ask what is happening.
D
25. Aclientlostcontrolofhisbehavior,brokeawindow,andmadeverbalthreatsto staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client? A) The length of time you'll be in restraints is undetermined. B) The staff will monitor your behavior closely. C) This is what happens when you lose control. D) This is a means of keeping you and others safe.
D
26. A client has just been served divorce papers from a spouse. The client has no financial resources and little social support. The client states, "My spouse is not really leaving, they will be back." Which is the most therapeutic response by the nurse? A. "Has your spouse done this before?" B. "I'll call social services and get you signed up for financial assistance." C. "You have to face reality. Here are the papers." D. "How is this affecting you right now?"
D
27. A nurse is assigned to administer oral medications to a client. Which actions will the nurse take if a client refuses to take prescribed oral medications? A. Inform the client that the nurse will get reprimanded for not administering the medication. B. Inform the client that refusal is not permitted and it is required that the client take the medication. C. Document the client's refusal on the medication administration record without comment. D. Ask the client's reason for refusing and report it to the health care provider.
D
27. Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain.
D
28. A client who has been grieving the loss of the client's spouse 2 weeks ago says to the nurse, "The best part of my day is when I am back at work. Is that wrong?" Which is the most therapeutic response by the nurse? A. "You cannot work effectively this soon. You should finish grieving first." B. "Working reminds you of your loss. It may be too early to go back." C. "Working is your way of avoiding grief, which will make it harder for you to move on." D. "Working is letting you take an emotional break from grieving. There's nothing wrong with that."
D
29. Afteranangryoutburst,theclientistearfulandremorseful.Whichstatementby the nurse would be most supportive? A) You still need to work on your problem-solving skills. B) I will not allow you to get that angry again. C) You should not have let your anger buildup like you did. D) What could you have done when you first started to feel angry?
D
30. A nurse is providing care to a client who has just delivered a stillborn infant. Which would be the most appropriate nursing response to address the client's grief? A. "Can I do anything for you?" B. "If something was wrong, it's better this way." C. "Your child is in heaven with God now." D. "Would you like to hold your child?"
D
31. Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger
D
34. A nurse is caring for a client who is grieving the loss of a loved one. Which factor will the nurse identify as contributing to the possibility of complicated bereavement? A. The client was relatively independent of the deceased. B. The client had few unresolved conflicts in the relationship with the deceased. C. The client has a good support system with meaningful relationships evident. D. The client has experienced a number of previous losses.
D
36. The nurse is working with a client who lost a life partner nearly 3 weeks ago. The client has recently become less emotional and expressed an interest in possibly returning to work. Which response by the nurse is most appropriate at this time? A. "I am concerned. You are starting to show signs of ineffective grieving." B. "You must feel some anger. It is all right to let that out." C. "Let's look at the things in your life that you still enjoy." D. "You are just starting to accept that this loss is real."
D
5.The nurse is performing an assessment for a client that is unkempt and withdrawn and reports fatigue and spending most of the days in bed after losing a job. Which is the most therapeutic response by the nurse? A. "Why did you lose your job? B. "Have you considered looking for another job?" C. "Do you have a history of depression?" D. "Have you considered harming yourself?"
D
8. The nurse is working in the Emergency Department and caring for several clients. Which client situation will require the nurse to break confidentiality and warn a third party? A. An abused client states, "I have dreams that they are dead." B. A client states, "Sometimes I feel like killing my kids!" C. A paranoid client states, "I'll get them before they get me." D. A jealous client states, "I am getting my gun and going to shoot my spouse's lover!"
D
9. A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate? A. Inform the client that without the medications, their mental status will not improve. B. Prepare discharge paperwork since the client is refusing assistance. C. Inform the client that a family member will be called to see if they can help. D. Set clear boundaries for behavior and allow the refusal of medication
D
Which one of the following statements about anger is most accurate? A) Anger is an abnormal human emotion that is always negative. B) It is best to express anger by whatever means possible to minimize its consequences. C) Most men are socialized to suppress anger. D) Anger awareness and expression are necessary for women's growth and development.
D
