Exam 2 Practice Questions

1. Contact the client's health care provider.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? 1. Contact the client's health care provider. 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

2. Use an indirect light source and turn off the television.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially? 1. Move the client next to the nurses' 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.

3. "You're feeling angry that your family continues to hope for you to be cured?"

A client diagnosed with terminal cancer says to 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."

2. Evidence of the client's disturbed body image

A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replaces the client's old clothes. The client believes that the new clothes are much too tight and has reduced her caloric intake to 800 calories daily. How should the nurse evaluates 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.

3. Increasing the level of suicide precautions

A moderatley depressed client who has hospitalized 2 days ago suddenlt begind smiling and reporting that the crisis is over. The client says to te 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

4. A willingness to participate in the planning of the care and treatment plan

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 toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan

4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse sould consider which factor? 1. A crisis state indicates that the client had 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 constitute a crisis for another client.

2. Assess and treat the wound sites.

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety 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. "What do you find difficult about this situation?"

The spouse of a client admitted to the mental health unit for alcohol withdrawal says tot he nurse, "I should get out of this bad situational." 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."

4. Thank the client for the input, but inform the client that others now need a chance to contribute

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

1. Information regarding shelters

The emergency department nurse is caring for an adult client who is a victims 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

2. Ask the client about the amount of drug use and its effect.

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 feat that the client is in denial and will throw he nurse out of the home.

2. Battery 3. Assault 5. False Imprisonment

The nurse calls security and has physical restraints applied to a client who has 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? SATA 1. Libel 2. Battery 3. Assault 4. Slander 5. False Imprisonment

2. Interrupt the client and offer to take her for a walk.

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 pushups. which nursing action is most appropriate? 1. Interrupt the client and weigh her ASAP 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program 4. Tell he client that she is not allowed to exercise vigorously.

2. Identifying anxiety-producing situations

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

1. Tremors

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 4. Excessively below normal

2. A client undergoing diagnostic tests

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted patient will be assigned to this client's room. Which client would be the BEST choice s 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 assistance at mealtime

4. "You sound very upset. Are you thinking of hurting yourself?"

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

1. Use open-ended questions and silence

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. Use open-ended questions and silence d questions and silence2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

3. Conversion disorder

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 testig vannot 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. Assigning to the client a staff member who will remain with the client at times.

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 who will remain with the client at times. 4. Admitting the client to a seclusion room were all potentially dangerous articles are removed.

4. A structured program of activities in which the client can participate

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. Encouraging 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 milieu 4. A structured program of activities in which the client can participate

2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 5. "I might have died over a few dollars in my pocket."

A client is admitted with a recent history of severe anxiety following home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? SATA 1. "I'm afraid of spiders." 2. "I keep 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 and over again many times."

1. Milieu therapy

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. Behavioral modification 4. Support group therapy

1. Admitting to having a problem

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which i 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 will people who gamble

1. Avoidant

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him and 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

3. Client arrives at the clinic neat and appropriate in appearance.

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 complaining 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 to 4 hours during the day.

3. "Do you feel afraid that people are trying to hurt you?"

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 don't 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?"

4. "You've been feeling like a failure for awhile?"

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 awhile?

3. "Tell me more about the incident that causes you to feel like the rape just occurred."

A female victim of a 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 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 bout 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. Crackers 5. Tossed salad

A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? SATA 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies

1. Call the nursing supervisor

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'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 the client cannot return to this hospital again if the client leaves now.

3. Escort the client to their room, with assistance of other staff

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 assistance of other staff 4. Tell the client that their telephone privileges are revoked for 24 hours.

1. "I no longer feel that I deserve the beatings my husband inflicts on me."

The nurse determines that the wide of an alcoholic client is benefiting from attending an al-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 eh meeting 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. "I cannot discuss any client situational with you."

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 ,y best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situational 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 is improving." 4. "Being her friend, you know she is having a difficult time and deserves her privacy."

2. Acknowledgement the client's behaviors 3. Assist the client to an area that is quiet 4. Maintain a safe distance from the client

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

2. Reactions to a devastating event

The nurse in the emergency department 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

1. Restating 2. Active listening 4. Maintaining neutral responses 5. Providing acknowledgment and feedback

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? SATA 1. Restating 2. Active listening 3. Asking the client, "why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disproval

4. Hypertension, changes in level of consciousness, hallucinations

The nurse is assessing a client who was admitted 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 level of consciousness, hallucinations

2. Avoid using a whisper voice in from of the client.

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 take> 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice in from 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.

3. Sit beside the client in silence with simple open-ended questions.

The nurse is caring for a client just admitted to the mental health unit and s=diagnosed with catatonic stupor. The client is lying on the bed in a fetal position, Which i 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 into the dayroom with other clients to provide stimulation.

1. Setting limits on the client's behavior

The nurse is conducing a group therapy session. During the session, a cliney diagnosed with ,ania 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

3. "What leads you to seek help now?"

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?"

2. Writing

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Board games 4. Group exercise

1. One-to-one suicide precautions

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 every15 minutes 4. Asking the client to report suicidal thoughts immediately

3. "When I have command hallucinations, I'll call a friend for help."

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 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 anxious feeling anxious."

1. Dental; decay 3. Loss of tooth enamel 4. Electrolyte imbalances

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? SATA 1. Dental; decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

2. The death of a loved one

The nurse is reviewing the assessment data of a client admitted to the mental health unit.. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for a 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

4. Inquiring about and examining the client's feelings for any that may black adaptive coping.

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 black adaptive coping.

1. Provide safety for the client and other clients on these unit

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is paid, 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 these 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.

3. "You seem restless; tell me what is happening."

The nurse observes that a client with a potential for violence is agitates, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which 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 changed your behavior."

1 .The group evaluates the experience. 6. The group explores members' feelings about the group and the impending separation.

The nurse should plan which goals of termination stage of group development? 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 takes place. 6. The group explores members' feelings about the group and the impending separation.

3. You're having difficulty sleeping?

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? 1. I see 3. Really? 3. You're having difficulty sleeping? 4. Sometimes I have trouble sleeping too

4. Helping the client to examine dysfunctional thoughts and beliefs

When a client is admitted to a 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 interaction with client who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

1. Monitor closely for harm to self or others

When reviewing 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 her or his mental health problem 4. Provide an opportunity for the family to discuss why they left the admission was needed

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

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 while speaking on the telephone and slams down the receiver. 4. The adolescent get angry with her roommate when the roommate borrows the client's clothes without asking.

1. Monitor vitals 2. Provide a safe environment 3. Address hallucinations therapeutically 5. Provide reality orientation as appropriate

Which interventions are most appropriate for caring for client in alcohol withdrawal? SATA 1. Monitor vitals 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. Communicate expected behaviors to the client 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 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SATA 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 of informing the client that he/she will onto be allowed to attend therapy groups 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable