Quiz #2 Practice Questions

A nurse is helping a client's family prepare to have an intervention that hopefully will encourage the alcoholic father to realize the need for change. Which of the following instructions by the nurse to the client's family members would be most effective? Select all that apply: 1. "Express your love and your belief that he can change." 2. "Point out that his behavior is his choice and his responsibility." 3. "Let him know that you understand how much he loves being with his drinking pals and that you agree that their friendship is important." 4. "Remind him that entering treatment is better than going to prison."

1, 2

Violence may occur anywhere in the hospital, but it is most frequent in which areas? (Select all that apply): 1. Psychiatric Units 2. Emergency Departments 3. Waiting Rooms 4. Geriatric Units 5. Outpatient mental health clinics 6. Community health settings 7. Schools

1, 2, 3, 4

Without therapy, the long-term the effects of trauma and violence may include which of the following? (Select all that apply): 1. Anger, resentment, fatigue 2. Post-traumatic stress disorder (PTSD) 3. Depression, insomnia 4. Obesity, improper nutrition 5. Optimism, hopefulness 6. High productivity

1, 2, 3, 4

Nurses are mandated reporters of which of the following situations? Select all that apply 1. Suspected child abuse 2. Physical evidence of child abuse 3. Sexually transmitted infection in a child 4. A school-aged child who is dirty, malnourished, and appears to have head lice 5. A thin, elder nursing home resident with multiple bruises and abrasions who will not make eye contact when you ask how he is feeling about his living situation 6. An adult woman who is reluctant to file a report on her female partner who hits her regularly when they are both intoxicated.

1, 2, 3, 4, 5

The CIWA alcohol withdrawal assessment tool assesses the presence of which of the following? (Select all that apply) 1. Nausea/Vomiting 2. Auditory Disturbances 3. Visual Disturbances 4. Tactile Disturbances 5. Diaphoresis 6. Depression 7. Headache 8. Paranoid Ideation 9. Thought Content 10. Short-term memory 11. Anxiety 12. Orientation to person, place, situation

1, 2, 3, 4, 5, 7, 11, 12

Which are the most common risk factors for a patient to become violent? 1. Substance use 2. Pain 3. Head injuries 4. Past history of violent behavior 5. Being suicidal 6. Mandated treatment settings 7. Most mentally ill patients 8. Specific medical diagnoses

1, 2, 3, 4, 6, 8

A nurse implementing a CIWA-Ar alcohol detox protocol for a patient in alcohol withdrawal will often give which of the following benzodiazepine medications to safely detox the patient? (Select all that apply): 1. Ativan (Lorazepam) 2. Librium (Chlordiazepoxide) 3. Buspar (Buspirone) 4. Lithium (Lithobid) 5. Clozaril (Clozapine) 6. Klonopin (Clonazepam) 7. Valium (Diazepam)

1, 2, 6, 7

A client requests help to stop smoking. Which of the following methods would be the best for the nurse to suggest to the client? Select all that apply: 1. A combination of interventions, beginning with changing the environment . 2. Acupuncture or Chantix alone as monotherapy to reduce the nicotine cravings. 3. Behavior modification through hypnosis with support and possibly medications. 4. Nicotine replacement products such as the Nicotine patch. 5. Wellbutrin (Buproprion, Zyban) with lifestyle modification and support.

1, 3, 4, 5

Non-verbal skills to prevent an already tense situation from increasing include which of the following? (Select all that apply): 1. Project an outwardly calm, confident demeanor with non-threatening eye contact. 2. Smile and keep your hands in your pockets or behind your back. 3. Listen and nod your head to demonstrate that you are paying attention. 4. Respect personal space. Maintain arm/leg distance away from the individual. 5. Approach the patient directly and do vital signs as usual. 6. Approach the patient from an angle or from the side. 7. Verbally tell the patient that you are in control and that they need to listen. 8. All of the above.

1, 3, 4, 6

The nurse can assist a patient to prevent substance use relapse by which of the following? Select all that apply: 1. rehearsing techniques to handle anticipated stressful situations. 2. advising the patient to accept residential treatment if relapse occurs. 3. assisting the patient to identify life skills needed for effective coping. 4. advising isolating self from significant others until sobriety is established. 5. informing the patient of physical changes to expect as the body adapts to functioning without substances.

1, 3, 5

A nurse is applying secondary prevention for a client for Substance Use Disorders (SUDs). Which of the following actions would the nurse most likely complete? Select all that apply: 1. Assist with identifying help or resources. 2. Advise about the need to enter a treatment program. 3. Ask about how relationships with family members and friends have been affected. 4. Assess amount and pattern of use. 5. Use a tool such as the CAGE or MAST scale.

1, 4, 5

Prevention and reduction of workplace violence includes which of the following? (Select all that apply): 1. Being aware of noise, the stress of the environment 2. Removing objects that can be used as weapons including unnecessary medical equipment 3. Being aware of your own body language, biases, behaviors, and voice tone 4. Identifying non-verbal patient cures such as looks signifying fear, high anxiety, or a fixed stare 5. Being aware of escalating patient behaviors such as heavy breathing, pacing, agitation or clenched fists 6. Identification of a patient's behavioral or verbal changes like confusion, neglected hygiene, or a louder voice 7. Use of tools such as STAMP (staring/eye contact, tone, anxiety, mumbling, pacing) 8. Paying attention to your own countertransference feelings or "6th sense", instincts and intuition with patients. 9. Travel with a cell phone when you are out in community settings 10. Recognition of any personal abuse history that can influence your own thinking and behaviors 11. All of the above

11

Which of the following are considered examples of violence? (Select all that apply): 1. An elderly confused patient will not eat or take her medications and becomes frustrated saying, "I don't want that poison!" 2. An elderly confused patient who is wandering into other patients rooms at night pushes a nurse who is trying to redirect the patient back to her room. 3. An elderly confused patient calls the nurse an offensive name. 4. A disturbed family member who father died in surgery threatens the nurses and surgeon with bodily harm. 5. An agitated psychotic patient scratches and spits at a nurse who is offering the patient medication. 6. An agitated psychotic patient yells obscenities in the ED waiting room at no one in particular. 7. A fearful psychotic patient lashes out verbally at a nurse who he perceives is trying to harm him. 8. A fearful psychotic patient lashes out with his arms and legs at a nurse who he perceives is trying to harm him. 9. All of the above.

2, 3, 4, 5, 7, 8 General agitation not directed at anyone in particular is not considered violence. Any directed behavior (verbal abuse, verbal threats, or physical actions) towards another (even if the act is not intentional or intended to harm, may be considered violence such as in the example of a confused elder or person who is psychotic who lashes out directly at a nurse in 'self-defense'). The other important concept to consider is that violence is not always physical. It can be psychological, verbal, emotional.

Which of the following include the staff nurse's role in workplace violence prevention? (Select all that apply): 1. Writing organizational safety protocols in compliance with OSHA guidelines. 2. Recognizing verbal and behavioral cues in others' that may signal stress or violence potential. 3. Assess patients' assault, homicidal and suicidal ideation and risks often. 4. Attend personal safety training programs by the organization. 5. Alert supervisors to any concerns and report all incidents as soon as possible and adherent to organizational procedures. 6. Go to work and do your job and only become concerned about an incident if and when it occurs. 7. Live your life without being too overly cautious because these incidents rarely happen. 8. Avoid wearing overly restrictive or loose clothing, dangly earrings, necklaces, scarves and pony tails. 9. Mind your own business and don't get too involved with any "office drama" amongst colleagues who are mean to each other. 10. All of the above

2, 3, 4, 5, 8

A teacher sends a student to the school nurse because the student does not seem to be thinking clearly. The nurse notes that the student is having palpitations, as well as elevated pulse, blood pressure, dizziness and sweating. Active use of which drugs could potentially account for these symptoms? Select all that apply: 1. Alcohol 2. Ecstasy (MDMA) 3. Methylphenidate 4. Marijuana 5. Huffing household cleaning substances

2, 3, 5

A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to do which of the following? Select all that apply: 1. avoid aged cheeses. 2. avoid alcohol-based skin products. 3. read labels of all liquid medications. 4. wear sunscreen and avoid bright sunlight. 5. maintain an adequate dietary intake of sodium. 6. avoid breathing fumes of paints, stains, and stripping compounds.

2, 3, 6

An MD has ordered a CIWA-Ar tool (Clinical Institute for the withdrawal from alcohol-revised) to be used as part of an alcohol detoxification protocol. You know that the CIWA-Ar is assessed on a numerical scale. Which of the following are true regarding the CIWA-Ar scale? (Select all that apply) 1. The highest score is 75. 2. The highest score is 67. 3. A score of 0-9 indicates severe withdrawal 4. A score of 0-9 indicates absent or minimal withdrawal 5. The higher the score, the more medication is given 6. A score > 35 indicates a possible transfer to the ICU 7. A patient who receives more than 8 mg of Lorazepam or 5mg of Diazepam in 3 hours is a candidate for ICU level of care. 8. A patient in alcohol withdrawal who receives benzodiazepines should be assessed for respiratory depression. 9. There are 10 parameters that are assessed 10. Vital signs are part of the determination about how much medication is given

2, 4, 5, 6, 8, 9, 10

Which of the following is an accurate concern about the use of marijuana? Select all that apply: 1. Marijuana has painful withdrawal symptoms. 2. Marijuana may damage the respiratory tract. 3. Marijuana can often reduce pain but physicians refuse to prescribe it. 4. Marijuana quickly leads to psychological and physiological dependence. 5. Use of Marijuana at a young age is associated with the development of psychotic symptoms.

2, 5

Which of the following statements accurately describes why methadone is used to treat heroin addiction? Select all that apply: 1. Addicts prefer Methadone instead of heroin. 2. Methadone blocks the effects of heroin and reduces the craving. 3. Methadone prevents further dependence on drugs. 4. Methadone gives an enjoyable high, so addicts continue treatment. 5. Methadone is a harm-reduction approach since it is regulated and considered less harmful than street drugs.

2, 5

A male IDU (injection drug user) admits to the nurse that he has no desire to stop using drugs, so rather than lecture him on the dangers of drug addiction, the nurse counsels him on how to sterilize his needles. Which of the following prevention efforts is the nurse attempting to achieve? Select all that apply: 1. Primary prevention by educating about safe injections. 2. Primary prevention by avoidance of future legal complications. 3. Secondary prevention to reduce the risk for infection or other complications. 4. Tertiary prevention to reduce the transmission of blood-borne diseases. 5. Harm Reduction to minimize complications to the client and community.

4, 5

A patient took a large quantity of the designer drug, 'psychoactive bath salts' (PABS). A nurse is familiar with the risks associated with this street drug. Priority nursing and medical measures include which of the following? Select all that apply: 1. administration of naloxone (Narcan). 2. vitamin B12 and folate supplements. 3. restoring nutritional integrity. 4. management of heart rate. 5. environmental safety.

4, 5

Long-term effects of violence include which of the following? (Select all that apply): 1. Low productivity 2. Work absences 3. Depression and low morale 4. Lack of trust in management 5. Loss of team cohesion 6. High worker turnover 7. Anxiety and stress 8. All of the above

8

Nurses are considered mandated reporters of which of the following? Select all that apply: A. most sexually transmitted infections (STI's) and Communicable Diseases. B. suspected child abuse and neglect even if there are no obvious signs. C. assessment findings of elder neglect and physical abuse. D. a woman who has a specific plan to kill her ex-husband with her car this afternoon. E. all cases of intimate partner violence (IPV) even if the victim does not agree to report abuse.

A, B, C, D

A client with psychosis became aggressive, struck another client, and required seclusion. Which one of the following is the most accurate and correct documentation? A. "Client pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 client yelled, "I'll punch anyone who gets near me," and struck another client with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430." B. "Client struck a peer who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two clients away from each other for 24 hours." C. "Seclusion ordered by physician at 1415 after command hallucinations told the client to hit another client. Careful monitoring of client maintained during period of seclusion." D. "Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Client calmer and apologized for outburst."

A. "Client pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 client yelled, "I'll punch anyone who gets near me," and struck another client with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430."

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" The nurse's best response is which one? A. "Make your loved one responsible for the consequences of behavior." B. "It's important that you visit your family member on a regular basis." C. "Alcoholism is a lifelong disease. Relapses are expected." D. "Use search and destroy tactics to keep the home alcohol free."

A. "Make your loved one responsible for the consequences of behavior."

Limit-setting is a technique that when properly applied can defuse potentially violent and risky situations as well as with challenging or difficult patients in general. Which statement is the best example of appropriate limit-setting with a patient? A. "Mr. Jones, I need for you to bring your voice down so that I can better hear and help you." B. "See how I am in control of my behavior? I was hoping that you could watch me and try your best to do the same." C. "Mr. Jones, if you don't stop that right now, I am going to put you in restraints!" D. "I cannot believe how terrible you are behaving Mr. Jones. It is really unacceptable."

A. "Mr. Jones, I need for you to bring your voice down so that I can better hear and help you."

During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? A. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." B. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." C. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." D. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

A. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."

According to the epidemiological evidence-base regarding risk factors for violence, which one of the following individuals is most at-risk for being involved with violence (as either a perpetrator of violence or as a potential victim)? A. A 19 year old male who currently attends college and has relations to a gang B. A 17 year old Caucasian woman who recently separated from her boyfriend C. A 78 year old elder man with dementia D. A 32 year old woman who is a former gang member and who has been to prison multiple times for vandalism and theft

A. A 19 year old male who currently attends college and has relations to a gang

A nurse is conducting an admission interview with Calista, a female client who was raped 2 weeks ago. When asked about the rape, Calista becomes very anxious and upset and begins to sob. Which one of the following nursing actions would be the most therapeutic next course of action? A. Acknowledge that the topic is upsetting and reassure Calista that it can be discussed at another time when she feels more comfortable. B. Reassure Calista that anything she says to you will remain confidential. C. Push Calista gently for more information about the rape details and explain that you need to document them in her chart. D. Use silence as a therapeutic tool and wait until Calista is done sobbing, then continue to discuss the details of what happened during the rape.

A. Acknowledge that the topic is upsetting and reassure Calista that it can be discussed at another time when she feels more comfortable.

A new client admits to being sexually coerced and emotionally abused by her live-in boyfriend over the past few years. She states, "We plan to get married next June. Things will be better then. He is always sorry afterwards and I think having a baby will help him to change." Which one of the following is a priority intervention to be included in the nurse's teaching plan? A. Develop an emergency plan for her since the violence is likely to continue. B. Support her hope that he will change and supporting her decision to stay in the relationship until they are married. C. Encourage her to enroll in a self-defense class. D. Suggest that if she gets pregnant the domestic violence pattern may end. E. Tell her that you, the nurse must report this abuse to the police.

A. Develop an emergency plan for her since the violence is likely to continue.

Which one of the following is the most therapeutic approach for a nurse working with a patient beginning treatment for alcohol addiction? A. Empathetic, supportive B. Confrontational C. Cool, distant D. Skeptical, guarded

A. Empathetic, supportive

A 6 year-old child is brought by her parents to the Emergency Department (ED) for a spiral fractured arm. The nurse notices several partially healed scars and bruises over her body. The parents state that she fell off her bicycle and that she is "accident-prone". The chart notes a history of multiple previous injuries since infancy. The most important, nursing action is for the nurse to do is which one of the following? A. Follow the ED procedure for reporting suspected child abuse B. Refer the family to their local pediatrician for a referral to Child Protective Services (CPS) C. Observe the family interactions, chart her suspicions in the chart, and ask to see the client again for follow-up D. Ask the child to explain all of her bruises and scars on her body

A. Follow the ED procedure for reporting suspected child abuse

Which one is the priority nursing intervention when caring for a patient after an overdose of amphetamines? A. Monitor vital signs B. Use warmers to maintain body temperature. C. Awaken the patient every 15 minutes. D. Observe for depression

A. Monitor vital signs

A patient on an inpatient locked psychiatric unit is exhibiting violent behavior towards staff. After an attempt to use a de-escalation method, the patient continues to escalate. As a result, it is decided that the patient needs to be put in seclusion and restraints. What do the legal guidelines state in regards to necessary nursing actions once the patient is restrained? (choose one) A. Obtain an MD order for seclusion and restraints, assess the patient every 15 minutes for behavior, vital signs, circulations, and skin assessments. Then document accordingly. B. There are no legal guidelines. Nurses must use their own discretion to decide how to proceed. C. Assess the patient every 15 minutes for behavior, vital signs, circulation, and skin assessments. Then document accordingly. D. Check on the patient every hour until they have calmed down enough to be released from restraints, document each time the patient is assessed.

A. Obtain an MD order for seclusion and restraints, assess the patient every 15 minutes for behavior, vital signs, circulations, and skin assessments. Then document accordingly.

A patient with an antisocial personality disorder (ASPD) was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? A. Residential program B. Long-term outpatient therapy C. 1-week detoxification program D. 12 step self help program

A. Residential program

Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? A. Simple and safe B. Confrontational and challenging C. Active and bright D. Stimulating and colorful

A. Simple and safe

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? A. Substance Abuse and Mental Health Services Administration (SAMHSA) B. American Society of Addictions Medicine (ASAM) C. National Council of State Boards of Nursing (NCSBN) D. Institute of Medicine - National Research Council (IOM)

A. Substance Abuse and Mental Health Services Administration (SAMHSA)

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? A. Tolerance has developed B. Metabolism of the alcohol is now delayed C. Antagonistic effects are evident D. Pharmacokinetics of the alcohol have changed

A. Tolerance has developed

Which one is the best example of the use of Primary Prevention for family violence?: A. Working to eliminate the glamorization of violence in the media B. Counseling a woman living in an abusive relationship about shelter programs C. Examining the bruises on the skin of an elderly nursing home resident who has just returned from a visit at home with his family D. Calling CPS regarding school aged children who has reported sexual abuse by her father

A. Working to eliminate the glamorization of violence in the media

Cognitive manifestations of a patient in Crisis involve which symptoms? A. inability to concentrate, problem-solve or make decisions B. stomach problems such as pain, nausea or vomiting C. sleep problems and nightmares D. anxiety and stress

A. inability to concentrate, problem-solve or make decisions Cognitive implies thinking problems

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Which is the most accurate assessment of this patient? A. the patient has symptoms of alcohol-withdrawal delirium. B. the patient is having an acute psychosis. C. the patient may have sustained a head injury before admission. D. the patient is attempting to obtain attention by manipulating staff.

A. the patient has symptoms of alcohol-withdrawal delirium.

A novice nurse is assigned to manage the milieu when there is a behavioral crisis with a client in the dining room. The nurse shows a clear understanding of crisis management when he/she does which of the following? Select all that apply: A. The nurse requires that all clients go in their rooms. B. The nurse clears the clients from the dining room to the day room/solarium. C. The nurse encourages the clients to express their reactions to the incident. D. The nurse reassures clients that staff will handle the agitated client. E. The nurse loudly tells all of the clients to "stay out of the way!'"

B, C, D

Which of the following are necessary for a nurse to do in order to effectively assess and deal with a child whom the nurse suspects is being abused? Select all that apply: A. Complete a certification course to work with abused children, otherwise refer the case to the social worker. B. Thoroughly, accurately document, and photograph any signs or symptoms of abuse. C. Be familiar with the common signs and symptoms of abuse and the appropriate reporting agencies in your area. D. Observe and listen to the child and family together as well as separately. E. Report the suspected child abuse to the local child protective services agency.

B, C, D, E

Which scenario best describes a behavioral crisis? (think safety priority) A. A client is crying hysterically after receiving a phone call from a family member. B. A client is waving fists, cursing, and shouting threats at a nurse. C. A client is curled up in a corner of the bathroom, wrapped in a towel. D. A client is performing push-ups in the middle of the hall, forcing others to walk around.

B. A client is waving fists, cursing, and shouting threats at a nurse.

The parents of a 15-year-old seek to have their teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the client recognizes that these behaviors often occur in which one of the following clients? A. Adolescents who have eating disorders. B. Adolescents who have been abused. C. Adolescents who are attention seeking. D. Adolescents who are developmentally delayed.

B. Adolescents who have been abused.

You are a nurse on an inpatient psychiatric unit and observe two patients becoming agitated with one another. The patients start with insults and become increasingly loud and aggressive. There is a clear concern that the verbal altercation may escalate and become physical. As the nurse, your first action should be to do which one of the following?: A. Allow the patients to work this out on their own because this behavior is a healthy expression of their frustration B. Assess the scene to ensure your own safety before approaching the patients C. Call for help from the other nurses D. Attempt to separate the patients

B. Assess the scene to ensure your own safety before approaching the patients

When faced with an irritable, angry and potentially violent patient or colleague, the best tactic is to do which one of the following at that time? A. Be aware of your verbal and non-verbal communication and impact on others by asking them what they see. B. Be self-aware and familiar with your environment, seek help and follow your organization's policies. C. File a mandatory worker's compensation report and attend required therapy. D. Be aware that anxiety that escalates to violence is only experienced by fatigued patients. E. Use verbal and physical control tactics yourself to disempower and de-escalate the person yourself.

B. Be self-aware and familiar with your environment, seek help and follow your organization's policies.

Which one is the most important nursing intervention for a potentially violent patient who is currently angry and aggressive? A. Use of pharmacological interventions B. De-escalation of anger by asking the patient, "What is it that you need?" C. Allowing the patient to express themselves. D. Invading the patient's personal space to ensure the safety of others.

B. De-escalation of anger by asking the patient, "What is it that you need?"

A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring? (choose one) A. Referring a local resident to a community food bank. B. Encouraging persons to describe their memories and feelings about the event. C. Coordinating psychiatric home care services. D. Arranging transportation to the local community mental health center.

B. Encouraging persons to describe their memories and feelings about the event.

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? A. Methadone (Dolophine) B. Naltrexone (ReVia) C. Disulfiram (Antabuse) D. Bromocriptine (Parlodel) E. Clonidine (Catapres)

B. Naltrexone (ReVia)

While a husband briefly steps out of the exam room to sign forms, the client, his wife states, "I don't know what to do anymore. He doesn't want me to go anywhere while he's at work, not even to visit my sister or friends." Which one of the following nursing diagnoses would the nurse formulate in respect to this data? A. Ineffective Individual Coping related to victimization as evidenced by listening to husband's directions. B. Powerlessness related to victimization, as evidenced by inability to mobilize a plan of action. C. Violence related to abusive husband, as evidenced by victim's statement of fear. D. Self-esteem disturbance related to marriage, as evidenced by not being able to leave the house.

B. Powerlessness related to victimization, as evidenced by inability to mobilize a plan of action.

If you cannot defuse a potentially violent situation quickly, what is the highest priority intervention? (The first thing to do...) A. Report any violent incidents to your management. B. Remove yourself from the situation as quickly as possible. C. Ask a patient for help D. Take the patient down E. Call security for help

B. Remove yourself from the situation as quickly as possible.

In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. A. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. B. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. C. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. D. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

B. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min.

Which one is the best example of Secondary Prevention for family abuse and violence?: A. teaching new parents what to expect regarding normal child growth and development. B. calling Child Protective Services (CPS) for a 4 year-old with new onset Chlamydia (Sexually Transmitted Infection, STI). C. teaching children about "good touch" and "bad touch". D. assisting families to develop clear, honest communication patterns.

B. calling Child Protective Services (CPS) for a 4 year-old with new onset Chlamydia (Sexually Transmitted Infection, STI).

The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should do which one of the following? A. first treat the schizophrenia, then establish goals for substance abuse treatment. B. consider each diagnosis primary and provide simultaneous treatment. C. provide long-term care for the patient in a residential facility. D. withdraw the patient from cannabis, then treat the schizophrenia.

B. consider each diagnosis primary and provide simultaneous treatment.

Which one of the following nursing interventions will best assist a female client to disclose an experience of domestic violence (intimate partner violence, IPV)? A. show her a video on domestic violence and spousal abuse and then confront her about her own abuse. B. provide her with a safe, private and non-intimidating environment to communicate in. C. allow the client to initiate a discussion on the topic of violence. D. interview her in the presence of her partner. E. believe and advocate for her only if there are physical signs of trauma.

B. provide her with a safe, private and non-intimidating environment to communicate in.

Biophysical signs of a patient in Crisis involve which symptoms? A. inability to concentrate, problem-solve or make decisions B. stomach problems such as pain, nausea or vomiting C. acting impulsively such as driving dangerously D. becoming withdrawn and socially isolating oneself E. anxiety and stress

B. stomach problems such as pain, nausea or vomiting

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Use of which substance is most likely? A. Barbiturates B. Heroin C. Amphetamines D. PCP E. Alcohol

C. Amphetamines

A client in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Which one of the following is the nurse's most important action? A. Reply, "I'm glad you feel comfortable talking to me about it." B. File a written report with the agency's ethics committee. C. Anonymously report the abuse by phone to the local child protection agency. D. Respect nurse-patient relationship confidentiality.

C. Anonymously report the abuse by phone to the local child protection agency. Your patient is not the child so there is no "actual evidence" or even "suspected " abuse of "your patient" to report. You need to maintain the nurse-client relationship (trust-building) and by reporting with your name, you would violate that trust, which may result in the client ending this relationship and your inability to further take care of or advocate for your client. If you report anonymously, (since your patient is the abuser), you may still be able to help the client, and you have still done the appropriate and ethical action in reporting the suspected abuse, while maintaining the therapeutic alliance (trust) and the patient care can continue.

Three women were brought to the emergency department (ED) by ambulance after a two-car accident at a busy intersection. Which one of these tests should automatically be done under such circumstances? A. Breathalyzer B. AST, ALT C. BAL D. CPK E. CBC with diff

C. BAL

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? A. Ineffective coping B. Ineffective denial C. Risk for injury D. Disturbed sensory perception

C. Risk for injury

A nurse is working with a family experiencing family violence. Which one of the following rationales best explains why a nurse should be aware of personal feelings while working with this family? A. Self-awareness enhances the nurse's advocacy role. B. Strong positive feelings lead to healthy transference with the victim. C. Strong negative feelings (countertransference) can interfere with assessment, healthy boundaries and clear judgment. D. Positive feelings promote the development of sympathy for clients, which is necessary for good care.

C. Strong negative feelings (countertransference) can interfere with assessment, healthy boundaries and clear judgment.

As the nurse, you suspect that this 6 year old child is being abused. Which one is the correct required time period that the nurse must file a written report? A. Immediately or within the next 2 hours B. Within 48 hours C. Within 36 hours D. Within 24 hours

C. Within 36 hours

According to the evidence, motivation to change one's behavior in a positive way is most influenced by which one of the following? A. financial incentives for staying clean and sober B. hitting 'rock bottom' such as a from a significant crisis C. human connections D. legal threats of jail or prison time E. court-mandated treatment

C. human connections

Which one of the following scenarios predicts the highest risk for directing violent behavior toward others? A. A client with Obsessive-Compulsive disorder (OCD) who performs daily counting and hand-washing rituals. B. A client who completed alcohol withdrawal 2 weeks ago and is actively attending a rehabilitation program. C. A client with Major Depression with delusions of worthlessness who is worried that others can smell the bad odor emanating from his intact skin. D. A client with Paranoid Delusions who reports feeling afraid of being followed and attacked by others.

D. A client with Paranoid Delusions who reports feeling afraid of being followed and attacked by others.

Which goal for treatment of alcoholism should the nurse address first? A. Develop alternate coping strategies. B. Learn about addiction and recovery. C. Develop a peer support system. D. Achieve physiologic stability.

D. Achieve physiologic stability.

An elderly male client with multi-infarct dementia lashes out and tries to kick people who walk past him in the hallway of a skilled nursing facility. Therapeutic intervention by the nurse should begin by doing which one of the following? A. Gently touching the patient's arm. B. Directing the patient to cease the behavior. C. Asking the patient, "What do you need?" D. Calmly stating to the patient, "This is a safe place."

D. Calmly stating to the patient, "This is a safe place."

Which assessment findings are likely for an individual who recently injected heroin? A. Anxiety, restlessness, paranoid delusions B. Heightened sexuality, insomnia, euphoria C. Muscle aching, dilated pupils, tachycardia D. Drowsiness, constricted pupils, slurred speech

D. Drowsiness, constricted pupils, slurred speech

Which skill can be used to de-escalate a potentially violent patient in crisis? A. If a patient calls out an error that you made, ignore it and try to move on quickly. B. Ignore the behavior and walk away. C. If a patient is constantly complaining, do not bring it up with your supervisor. D. Offer an empathic response such as "I understand how upsetting (or frustrating or scary) this must be for you."

D. Offer an empathic response such as "I understand how upsetting (or frustrating or scary) this must be for you."

According to the stages of change theory, a person who is currently abusing substances and is in denial of the problem and not ready for change, is in which stage of change? A. Action stage B. Contemplative stage C. Planning Stage D. Pre-contemplative stage E. Resistance stage

D. Pre-contemplative stage

A school health nurse is asked by a parent group to explain risk factors for Substance Use Disorders (SUDs). Which one of the following information should the nurse include? A. SUDs are determined primarily by the family environment. B. Persons who use substances are usually women. C. Alcoholism is a disease of willpower. D. SUDs are determined partly by genetic factors. E. Persons born with fetal alcohol syndrome are alcoholics from birth.

D. SUDs are determined partly by genetic factors.

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? A. Obtain a face shield because oral hygiene is poor in methamphetamine abusers. B. Verify that security services are immediately available. C. Perform a thorough assessment of the patient. D. Self-assess personal attitude, values, and beliefs about this health problem.

D. Self-assess personal attitude, values, and beliefs about this health problem.

Students at first-day orientation at the local community college are discussing alcohol and drug abuse with their freshmen advisor. During a break, some students go outside for soft drinks and snacks. Soon after, the advisor walks by and notices several of these students smoking cigarettes. Based on this, which of the following topics of the drug and alcohol orientation would be most important for the advisor to reemphasize after the break? A. How students can learn to "just say no" when offered drugs or drinks. B. A discussion of which drugs are commonly used on campus. C. How to recognize and overcome peer pressure to continue bad habits. D. The fact that tobacco smoking causes more deaths than any other behavior in the United States.

D. The fact that tobacco smoking causes more deaths than any other behavior in the United States.

A movie shows a woman and a man having a contest to see who can drink more shots of whiskey. Who is more likely to "win" the drinking contest when the other passes out and cannot continue? A. If they play fair, they'll probably both vomit before passing out. B. The woman will win because females metabolize alcohol more slowly than men. C. If their drinks are the same size, they'll both pass out about the same time. D. The man will win.

D. The man will win.

A man is addicted to alcohol. In which of the following scenarios is a family member enabling the man to continue drinking? A. The son threatens to leave home because he finds the father's behavior embarrassing. B. The teenage daughter turns to a favorite teacher for emotional support. C. The wife asks the nurse to explain why her husband's continued drinking is dangerous. D. The wife tells her husband's boss that her husband is sick when he is actually inebriated.

D. The wife tells her husband's boss that her husband is sick when he is actually inebriated.

A hospitalized patient diagnosed with an alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe which one of the following? A. a monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil). B. the medication, Antabuse (Disulfram). C. an antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). D. a sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).

D. a sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).

Symptoms of withdrawal from opioids for which the nurse should assess include which one of the following list of symptoms? A. excessive eating, constipation, and headache. B. mood lability, incoordination, fever, and drowsiness. C. dilated pupils, tachycardia, elevated blood pressure, and elation. D. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

D. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will do which one of the following? A. develop a trusting relationship with one staff member. B. identify constructive outlets for expression of anger. C. use denial and rationalization in healthy ways. D. state, "I know I need long-term treatment."

D. state, "I know I need long-term treatment."

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? A. 5150 the patient B. Place the patient in a vest-type restraint C. Force fluids D. Obtain a clean-catch urine sample E. Consult the health care provider

E. Consult the health care provider

You, the nurse are assessing a tremulous medical surgical patient who was admitted earlier today for chronic pancreatitis. You notice that the admitting physician forgot to add an important assessment in the chart. Understanding a major cause of pancreatitis, you advocate for which assessment tool to be ordered for this patient? A. GDS (Geriatric Depression Scale) B. COWS (Clinical Opiate Withdrawal Scale) C. AIMS (Abnormal Involuntary Movement Scale) D. SAWS (Severity of Alcohol Withdrawal Scale) E. GCS (Glascow Coma Scale) F. CIWA-Ar (Clinical Institute for the Withdrawal of Alcohol-revised version)

F. CIWA-Ar (Clinical Institute for the Withdrawal of Alcohol-revised version)

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? A. Cardiovascular B. Dermatologic C. Hepatic D. Neurologic E. Endocrine F. Respiratory

F. Respiratory

True or False? Management and healthcare administration are the only parties who have a responsibility in maintaining a safe work environment, and preventing and responding to violence in the workplace.

False

True or False? According to the evidence-based approach, SBIRT (Screening, Brief Intervention & Referral to Treatment) when working with those with substance use disorders (and other problems), there is not much that health care professionals can do until a person is motivated to change.

False Motivation is accessible and can be modified or enhanced at many points in the change process. Nurses and other healthcare professionals can access a person's motivation and help move them forward towards positive behavior change well before extensive damage is done to health, relationships, or self-image.

True or False? Violence only refers to attacks with obvious physical signs and injuries. It never includes verbal or psychological injuries where there is no observable sign(s).

False Violence can be non-physical-- psychological, bullying, intimidation, coercion, emotional, and/or verbal in nature. There may be no obvious physical signs. This is a very important point- to reiterate that violence is not always about physical assault or signs; Violence can absolutely be emotional/psychological and is always about power, coercion and control.

True or False? Violent and an acutely distressed persons are primarily exerting their physical power over another and are often quite in control of their thinking, emotions and behaviors.

False Violence it is about the misuse of power to control another through physical or emotional manipulation and those who are distressed or in crisis are out of control on the cognitive, behavioral and emotional levels

True or False? There is almost always a financial impact related to violence due to lost wages, time off work, legal and direct care costs.

True The costs of violence are widespread and impact both the direct costs to treat / care for the victim as well as all of the indirect factors such as lost wages from work absenteeism, life disruptions and generational impact (cycle of violence).

You are the nurse examining a woman who reports that she has a history of being physically, mentally and sexually assaulted by her husband for several years. She is in active recovery. The chart notes a prior history of Rape Trauma Syndrome. She tells you that she is currently living in an emergency shelter to remain safe from him. The shelter address is not listed and she wishes this to be kept in confidence. After the client leaves, you see that the chart also contains signed confidentiality forms allowing her husband access to all of her medical information. What are the bio-ethical nursing actions that would apply to this case? Select all that apply: A. Protect the client's safety and do good by her. Do not give any information to the husband (Beneficence), even if he demands it. B. Do not intentionally harm the client (Non-Maleficence); Follow the intent of her words at her last visit; do not give out any information to her husband under any circumstance. C. The nurse should apply Fidelity to the client. She is your priority not her husband. D. Follow HIPPA and tell the husband the truth (Veracity) if he asks where the shelter is located. E. Respect client's Autonomy; she is on her own now and can handle the husband if he shows up. Follow the intent of the original signed forms and give the husband any information requested.

A, B, C

A public health nurse (PHN) is learning about Community Violence and knows that which of the following are accurate (true) statements? Select all that apply: A. Violence may involve mental pressure or coercion, psychological and physical effects B. The nursing profession is at high risk for violence. C. Risk factors for violence include social isolation, possession of a weapon, substance use disorders, crowded environments and living conditions. D. Inexperienced nurses who set inconsistent boundaries, use force or 'strong-arm' techniques with clients. E. Violence is defined as mainly physical aggression.

A, B, C, D

Which is one of the best interventions for a patient who has incurred violence? A. watchful waiting, give the person some space to work it out on their own in their own way B. share your own personal experiences with the person C. try to problem-solve for the person D. recommend medications for sleep E. offer empathy and support and an outlet to express general emotions such as journaling

E. offer empathy and support and an outlet to express general emotions such as journaling

A Community Health Nurse (CHN) would be involved in which of the following activities? Select all that apply: A. Administering blood products to an anemic patient and assess for a transfusion reaction on a medical-surgical unit. B. Identifying vulnerable sub-populations at risk for disease. C. Educating and empowering community members and stakeholders about pertinent health issues. D. Develop disaster plans, advocating for emergency preparedness, and triaging community members involved in a local disaster. E. Performing an emergency room triage assessment of a patient suspected of having a pulmonary embolism.

B, C, D

Which one of the following is a consistent conclusion of family violence research?: A. Family violence always involves weapons. B. Family violence rarely occurs in the United States C. Family violence readily responds to psychiatric medications D. Family violence is caused primarily from mental illness E. Family violence is perpetuated through generations by a cycle of violence

E. Family violence is perpetuated through generations by a cycle of violence

Which of the following approaches has research suggested is the most effective way to approach substance use disorders (SUDs)? A. Criminal justice system B. Punishment approach C. Zero tolerance D. Substance abuse education E. Harm reduction

E. Harm reduction

A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Which is the nurse's best response? A. "You will be assigned a sponsor who will plan your treatment program." B. "You must make a commitment to permanently abstain from alcohol and other drugs." C. "An individual is supported by peers while striving for abstinence one day at a time." D. "The goal of AA is for members to learn controlled drinking with the support of a higher power."

C. "An individual is supported by peers while striving for abstinence one day at a time."

Which one is the most correct way to document rape from a date? A. "Client stated that she had intercourse against her will." B. "Client claims she was forced to have sexual intercourse." C. "Client reports, 'My date raped me.' " D. "Client has been sexually assaulted."

C. "Client reports, 'My date raped me.' "

A woman has just delivered a baby and is lamenting that the baby's father is not with her. She shares with you that he became involved with drugs and is now in prison for theft. The new mother says, "It's so sad. He's clearly no good." Which of the following would be the best response by the nurse? A. "You must hate him for leaving you alone with a new baby!" B. "I'm so sorry to hear that. Is your mother able to be with you?" C. "Is there anyone to help you with the baby until the baby's father can be released and encouraged to get treatment for his addiction?" D. "It's good that you and the baby are safe from him."

C. "Is there anyone to help you with the baby until the baby's father can be released and encouraged to get treatment for his addiction?"

A patient diagnosed with an alcohol use disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? A. "I hear a lot of defensiveness in your voice. Do you really believe this?" B. "If you were coping so well, why were you hospitalized again?" C. "Tell me what happened the last time you drank." D. "Sooner or later, alcohol will kill you. Then what will happen to your children?"

C. "Tell me what happened the last time you drank."

A medical surgical patient is admitted for acute gastritis and you suspect it is related to chronic alcoholism. The patient is currently A &O X 4 but complains of intermittent nausea, moderate anxiety, a moderate headache, and moderate itching/pins and needles sensations in his extremities. The patient appears moderately fidgety and restless and complains of moderate sensitivity to light. You observe obvious diaphoresis on his forehead. He denies any other symptoms. You notice that he has severe tremors of both arms while they are resting on his stomach and his VS are all elevated. Which one would be the most accurate total score assigned for this patient using the CIWA-Ar? A. 40 B. 24 C. 34 D. 10 E. 18

C. 34

A hospitalized patient diagnosed with an alcohol use disorder believes that spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? A. Check the patient every 15 minutes. B. Immediately place physical restraints on the patient. C. Force fluids. D. Keep the room dimly lit E. One-on-one supervision.

E. One-on-one supervision.

Behavioral signs of a patient in Crisis involve which of the following? A. hyperventilating, developing a rash or hives B. inability to concentrate, problem-solve or make decisions C. stomach problems such as pain, nausea or vomiting D. hyperventilation, shaking or sweating E. acting impulsively such as driving dangerously or becoming easily angered

E. acting impulsively such as driving dangerously or becoming easily angered

Which one of the following are signs that an elder may be suffering from the "Neglect" type of elder abuse? A. the elder has a refusal to go to the same emergency room for repeated physical injuries. B. the elder is uncommunicative and evasive. C. there have been large cash withdrawals and unusual ATM activity in the elder's bank account. D. the elder has bed sores, sunken eyes and have lost weight.

D. the elder has bed sores, sunken eyes and have lost weight.