saunders quiz 6

A hospitalized client with a history of alcohol misuse tells the nurse "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor 2. Call security to block all exit areas 3. Restrain the client until the PHCP can be reached 4. Tell the client that they cannot return to this hospital again if they leave now

1

The ED nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self defense classes 4. Explaining the importance of leaving the violent situation

1

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One to one suicide precautions 2. Suicide precautions with 30 minute checks 3. Checking the whereabouts of the client every 15 mins 4. Asking the client to report suicidal thoughts immediately

1

a client experiencing disturbed thought processes believes that his food is being poisoned. which communication technique should the nurse use to encourage the client to eat? 1. using open ended questions and silence 2. sharing personal preference regarding food choices 3. documenting reasons why the client doesn't want to eat 4. offering opinions about the necessity of adequate nutrition

1

a client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. the nurse is implementing which therapeutic approach? 1. milieu therapy 2. interpersonal therapy 3. behavior modification 4. support group therapy

1

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SELECT ALL THAT APPLY 1. Monitor vital signs 2. Provide a safe environment 3. Address hallucinations therapeutically 4. Provide stimulation in the environment 5. Provide reality orientation as appropriate 6. Maintain NPO status

1, 2, 3, 5

the nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? SELECT ALL THAT APPLY 1. restating 2. active listening 3. asking the client why 4. maintaining neutral responses 5. providing acknowledgement and feedback 6. giving advice and approval or disapproval

1, 2, 4, 5

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? SELECT ALL THAT APPLY 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1, 3, 4

which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SELECT ALL THAT APPLY 1. communicate expected behaviors to the client 2. ensure that the client knows that they are not in charge of the nursing unit 3. assist the client in identifying ways of setting limits on personal behaviors 4. follow through about the consequences of behavior in a nonpunitive manner 5. enforce rules by informing the client that he/she will not be allowed to attend therapy groups 6. have the client state the consequences for behaving in ways that are viewed as unacceptable

1, 3, 4, 6

the nurse should plan which goals of he termination stage of group development? SELECT ALL THAT APPLY 1. the group evaluates the experience 2. the real work of the group is accomplished 3. group interaction involves superficial conversation 4. group members become acquainted with one another 5. some structuring of group norms, roles, and responsibilities take place 6. the group explores members' feelings about the group and the impending separation

1, 6

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately 2. Interrupt the client and offer to take her for a walk 3.allow the client to complete her exercise program 4. Tell the client that she is not allowed to exercise vigorously

2

The nurse is reviewing the assessment data of the client admitted to the mental health unit. The nurse notes that the admissions nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2

the nurse notes that a client diagnosed with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. the nurse determines that the client is experiencing which medication complication? 1. parkinsonism 2. tardive dyskinesia 3. hypertensive crisis 4. neuroleptic malignant syndrome

2

when planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. suppressing feelings of anxiety 2. identifying anxiety-producing situations 3. continuing contact with a crisis counselor 4. eliminating all anxiety from daily situations

2

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observed that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? SELECT ALL THAT APPLY 1. Initiate confinement measures 2. Acknowledge the client's behavior 3. Assist the client to a quiet area 4. Maintain a safe distance from the client 5. Allow the client to take control of the situation

2, 3, 4

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? SELECT ALL THAT APPLY 1. I'm afraid of spiders 2. I knew reliving the robbery 3. I see his face everywhere I go 4. I don't want anything to eat now 5. I might have died over a few dollars in my pocket 6. I have to wash my hands over and over again many times

2, 3, 5

the nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. which represents the possible legal ramifications for the nurse associated with these interventions? SELECT ALL THAT APPLY 1. libel 2. battery 3. assault 4. slander 5. false imprisonment

2, 3, 5

a hospitalized client is started on an MAOI for the treatment of depression. the nurse should instruct the client that which foods are acceptable to consume while taking this medication? SELECT ALL THAT APPLY 1. figs 2. yogurt 3. crackers 4. aged cheese 5. tossed salad 6. oatmeal raisin cookies

3, 5

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in LOC, hallucinations

4

The nurse is creating a plan of care for a client in a crisis state. When developing the plan the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness 2. A crisis state indicates that the client has an emotional illness 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not for another client

4

a client gives the home health nurse a bottle of clomipramine. the nurse notes that the medication has not been taken by the client in 2 months. which behavior noted in the client would validate noncompliance with this medication? 1. complaints of insomnia 2. complaints of hunger and fatigue 3. a pulse rate of less than 60 bpm 4. frequent hand washing with hot, soapy water

4

on review of the client's record, the nurse notes that the admission was voluntary. based on this information, the nurse plans care anticipating which client behavior? 1. fearfulness regarding treatment measures 2. anger and aggressiveness directed towards others 3. an understanding of the pathology and symptoms of the diagnosis 4. a willingness to participate in the planning of care and treatment plan

4

the nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. before discharge, which instruction should the nurse provide to the client? 1. get adequate sunlight 2. continue driving as usual 3. avoid foods rich in potassium 4. get up slowly when changing positions

4

the nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. exploring the client's ability to function 2. exploring the client's potential for self harm 3. inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. inquiring about and examining the client's feelings for any that may block adaptive coping

4

what is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. ask the client to leave the group for this session only 2. refer the client to another group that includes other manic clients 3. tell the client to stop monopolizing in a firm but compassionate manner 4. thank the client for the input, but inform the client that others now need a chance to contribute.

4

when receiving the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. based on this type of admission, the nurse should provide which intervention for this client? 1. monitor closely for harm to self or others 2. assist in completing an application for admission 3. supply the client with written information about his or her mental health problem 4. provide an opportunity for the family to discuss why they felt like the admission was needed

4

The nurse determines that the wife of an alcoholic client is benefitting from attending an AI-Anon group if the nurse hears the wife make which statement? 1. I no longer feel that I deserve the beatings my husband inflicts on me 2. My attendance at the meetings has helped me see that I provoke my husband's violence 3. I enjoy attending the meetings because they get me out of the house and away from my husband 4. I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics

1

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a dvd and a cherished autographed picture of a performer 2. The adolescent runs out of the therapy group swearing at the group leader and to her room 3. The adolescent becomes angry when speaking on the phone and slams down the receiver 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking

1

a client admitted voluntarily for treatment of an anxiety problem demands to be related from the hospital. which action should the nurse take initially? 1. contact the client's PHCP 2. call the client's family to arrange for transportation 3. attempt to persuade the client to stay for "only a few more days" 4. tell the client that leaving would likely result in an involuntary commitment

1

a client is preparing to attend a gambler's anonymous meeting for the first time. the nurse should tell the client that which is the first step in this 12 step program? 1. admitting to having a problem 2. substituting other activities for gambling 3. stating that the gambling will be stopped 4. discontinuing relationships with people who gamble

1

a client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. because of this hypersensitivity to a reaction from her, the client remains homebound. the home care nurse develops a plan of care that addresses which personality disorder? 1. avoidant 2. borderline 3. schizotypal 4. obsessive-compulsive

1

a client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. the lithium level is 2.5 mEq/L. the nurse plans care based on which representation of this level? 1. toxic 2. normal 3. slightly above normal 4. excessively below normal

1

the nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. the neighbor says to the nurse, "how is carol doing? She is my best friend and is seen at your clinic every week." which is the most appropriate nursing response? 1. I cannot discuss any client situation with you 2. if you want to know about carol, you need to ask her yourself 3. only because you're worried about a friend, I'll tell you that she's improving 4. being her friend, you know she is having a difficult time and deserves some privacy

1

the nurse is conducting a group therapy session. during the session, a client diagnosed with mania consistently disrupts the group's interactions. which intervention should the nurse initially implement? 1. setting limits on the client's behavior 2. asking the client to leave the group session 3. asking another nurse to escort the client out of the group session 4. telling the client that they will not be able to attend any future group sessions

1

the nurse observes that a client is pacing, agitated, and presenting aggressive gestures. the client's speech pattern is rapid, and affect is belligerent. based on these observations, which is the nurse's immediate priority of care? 1. provide safety for the client and other clients on the unit 2. provide the clients on the unit with a sense of comfort and safety 3. assist the staff in caring for the client in a controlled environment 4. offer the client a less stimulating area in which to calm down and gain control

1

when the client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. the nurse plans care based on which purpose of this approach? 1. providing a supportive environment 2. examining intrapsychic conflicts and past issues 3. emphasizing social interactions with clients who withdraw 4. helping clients examine dysfunctional thoughts and beliefs

1

A client with a diagnosis of anorexia nervosa who is in a state of starvation is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's presence at mealtimes

2

A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy new clothes but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

2

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs 2. Ask the client about the amount of drug use and its effect 3. Ask the client how long he thought that he could take drugs without someone finding out 4. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home

2

The nurse in the ED is caring for a young female victim of sexual assault. The client's physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2

The police arrive at the ED with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an anti anxiety agent 2. Assess and treat the wound sites 3. Secure and record a detailed history 4. Encourage and assist the client to ventilate feelings

2

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. Why don't you tell your spouse about this? 2. What do you find difficult about this situation? 3. This is not the best time to make that decision 4. I agree with you, you should get out of this situation

2

a client diagnosed with delirium becomes disoriented and confused at night. which intervention should the nurse implement initially? 1. move the client next to the nurse's station 2. use an indirect light source and turn off the television 3. keep the television and a soft light on during the night 4. play soft music during the night, and maintain a well-lit room

2

a client who has been taking buspirone for one month returns to the clinic for a follow up assessment. the nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. paranoid thought process 2. rapid heartbeat or anxiety 3. alcohol withdrawal symptoms 4. thought broadcasting or delusions

2

a client's medication sheet contains a prescription for sertraline. to ensure safe administration of the medication, how should the nurse administer the dose? 1. on an empty stomach 2. at the same time each evening 3. evenly spaced around the clock 4. as needed when the client complains of depression

2

a hospitalized client has begun taking bupropion as an antidepressant agent. the nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of this medication? 1. constipation 2. seizure activity 3. increased weight 4. dizziness when getting upright

2

the nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. in formulating a nursing plan of care, which best intervention should the nurse include? 1. encourage socialization of the client with peers 2. avoid using a whisper voice in front of the client 3. begin to educate the client about social supports in the community 4. have the client sign a release of information to appropriate parties for assessment purposes

2

the nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. which information should the nurse include in the discussion? 1. consume a low fiber diet 2. increase fluids and bulk in the diet 3. rest if the heart begins to beat rapidly 4. walk if you have difficulty urinating because this is a normal side effect

2

the nurse is performing a follow up teaching session with a client discharged one month ago. the client is taking fluoxetine. which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication? 1. cardiovascular symptoms 2. gastrointestinal dysfunctions 3. problems with mouth dryness 4. problems with excessive sweating

2

the nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. which activity would be the most appropriate for this client? 1. chess 2. writing 3. board games 4. group exercise

2

the nurse is teaching a client who is being started on imipramine about the medication. the nurse should inform the client to expect maximum desired effect at which time period following initiation of the medication? 1. in 2 months 2. in 2-3 weeks 3. during the first week 4. during the 6th week of administration

2

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning to the client a staff member that will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3

A female victim of sexual assault is being seen in the crisis center. The client states that she still feels as though the rape just happened yesterday even though it has been a few months since the incident. Which is the most appropriate nursing response? 1. You need to try to be realistic. The rape did not just occur 2. It will take some time to get over these feelings about your rape 3. Tell me more about the incident that causes you to feel like the rape just occurred 4. What do you think that you can do to alleviate some of your fears about being raped again?

3

A moderately depressed client who was hospitalized 2 days ago suddenly starts smiling and reporting that the crisis is over. The client says to the nurse "I'm finally cured." Based on the client's behavior and statement which intervention should the nurse include in the plan? 1. Suggesting a reduction of medication 2. Allowing increased "in room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3

A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. You need to stop that behavior now 2. You will need to be placed in seclusion 3. You seem restless, tell me what is happening 4. You will need to be restrained if you do not change your behavior

3

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. With whom do you live? 2. Who is available to help you? 3. What leads you to seek help now? 4. What do you usually do to feel better?

3

a client diagnosed with terminal cancer tells the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. after all, I'm the one who's dying." which response by the nurse is therapeutic? 1. have you shared your feelings with your family? 2. I think we should talk more about your anger with your family. 3. you're feeling angry that your family continues to hope for you to be cured? 4. you are probably very depressed, which is understandable with such a diagnosis.

3

a client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit and run accident. when diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. the nurse plans care based on which mental health condition? 1. psychosis 2. repression 3. conversion disorder 4. dissociative disorder

3

a client receiving tricyclic antidepressants arrives at the mental health clinic. which observation would indicate that the client is following the medication plan correctly? 1. client reports not going to work for the past week 2. client complains of not being able to "do anything" anymore 3. client arrives at the clinic neat and appropriate in appearance 4. client reports sleeping 12 hours per night and 3-4 hours during the day

3

a client says to the nurse, "the federal guards were sent to kill me." which is the best response by the nurse to the client's concern? 1. I dont believe this is true 2. the guards are not out to kill you 3. do you feel afraid that people are trying to hurt you? 4. what makes you think the guards were sent to hurt you?

3

a manic client begins to make sexual advances toward visitors in the dayroom. when the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. based on the analysis of this situation, which intervention should the nurse implement? 1. place the client in seclusion for 30 minutes 2. tell the client that the behavior is inappropriate 3. escort the client to their room with the assistance of other staff 4. tell the client that their telephone privileges are revoked for 24 hours

3

the nurse is caring for a client just admitted to the mental health unitard diagnosed with catatonic stupor. the client is lying in the bed in a fetal position. which is the most appropriate nursing intervention? 1. ask direct questions to encourage talking 2. leave the client alone so as to minimize external stimuli 3. sit beside the client in silence with simple open ended questions 4. take the client to the dayroom with other clients to provide stimulation

3

the nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1. my medications will help my anxious feelings 2. I'll go to a support group and talk about what I am feeling 3. when I have command hallucinations, I'll call a friend for help 4. I need to get enough sleep and eat well to help prevent feeling anxious

3

the nurse visits a client at home. the client states "I haven't slept at all the past couple of nights." which response by the nurse demonstrates therapeutic communication? 1. I see 2. really? 3. you're having difficulty sleeping? 4. sometimes I have trouble sleeping too

3

A depressed client on an inpatient unit says to the nurse "my family would be better off without me." Which is the nurses best response? 1. Have you talked to your family about this? 2. Everyone feels this way when they are depressed 3. You will feel better once your medication begins to work 4. You sound very upset. Are you thinking of hurting yourself?

4

a client is admitted to the mental health unit with a diagnosis of depression. the nurse should develop a plan of care for the client that includes which intervention? 1. encourage quiet reading and writing for the first few days 2. identification of physical activities that will provide exercise 3. no socializing activities until the client asks to participate in the milieu 4. a structured program of activities in which the client can participate

4

a client is scheduled for discharge and will be taking phenobarbital for an extended period. the nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. take the medication only with meals 2. take the medication at the same time each day 3. use a dose container to help prevent missed doses 4. avoid drinking alcohol while taking this medication

4

a client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. nothing ever goes right for me." which response by the nurse demonstrates therapeutic communication? 1. you have everything to live for 2. why do you see yourself as a failure? 3. feeling like this is all part of being depressed. 4. you've been feeling like a failure for a while?

4

a client with schizophrenia has been started on medication therapy with clozapine. the nurse should assess the results of which laboratory study to monitor fro adverse effects from this medication? 1. platelet count 2. blood glucose levels 3. liver function studies 4. WBC count

4