Mental Health Test Number 3

4. A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file. B. Instruct the client's partner to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

A. A power of attorney document does not address the client's care or the concerns of the caregiver. B. Clients in late‑stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not an appropriate action. C. CORRECT: Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities. D. Placement of an enteral feeding tube is appropriate only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members.

5. A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. unaltered level of consciousness E. Restlessness

A. A. the client who has delirium can experience memory loss with sudden rather than gradual onset. B. CORRECT: the client who has delirium can experience rapid personality changes. C. CORRECT: the client who has delirium can have perceptual disturbances, such as hallucinations and illusions. D. The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate. E. CORRECT: the client who has delirium commonly exhibits restlessness and agitation.

5. A nurse is conducting health screenings at a statewide health fair and identifies several clients who require referral to a provider. Which of the following statements by a client indicates a barrier to accessing health care? A. "I don't drive, and my son is only available to take me places in the mornings." B. "I can't take off during the day, and the local after‑hours clinic is no longer in operation." C. "Only one doctor in my town is a designated provider by my health maintenance organization." D. "I would like to schedule an appointment with the local doctor in my town who speaks Spanish and English."

A. Because the client has some form of transportation to the provider, this statement does not represent a barrier to accessing health care. The nurse should instruct the client to schedule a follow‑up appointment when the family member is available to drive. B. CORRECT: Inconvenient hours make scheduling a follow‑up appointment challenging, and indicates a barrier to accessing health care for this client. C. Because this client has an available provider, even though it is the only option, this statement does not represent a barrier to accessing health care. The nurse should instruct the client to schedule a follow‑up appointment with this provider. D. the presence of a provider who is bilingual represents increased access to health care because it increases accessibility for clients who might speak a different language

2. A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply.) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. altered level of consciousness E. increase in head circumference

A. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome. B. CORRECT: Respiratory distress is an expected finding of shaken baby syndrome. C. CORRECT: Retinal hemorrhage is an expected finding of shaken baby syndrome. D. CORRECT: an altered level of consciousness is an expected finding of shaken baby syndrome due to intracranial trauma or hemorrhage. E. CORRECT: an increase in head circumference is an expected finding of shaken baby syndrome.

1. A nurse at a community clinic is conducting a well‑child visit with a preschool‑age child. The nurse should identify which of the following manifestations as a possible indication of child neglect? (Select all that apply.) A. underweight B. healing spiral fracture of the arm C. Genital irritation D. Burns on the palms of the hands E. poor hygiene

A. CORRECT: Being underweight is a possible manifestation of child neglect. B. A healing spiral fracture is a possible manifestation of physical abuse. C. Genital irritation is a possible manifestation of sexual abuse. D. Burns on the palms of the hands are a possible manifestation of physical abuse. E. CORRECT: poor hygiene is possible manifestation of child neglect.

5. A nurse is collecting data to identify health needs in the local community. Which of the following examples should the nurse identify as secondary data? (Select all that apply.) A. Birth statistics B. Previous health survey results C. Windshield survey D. Community forum E. Health records

A. CORRECT: Birth statistics are an example of secondary data the nurse should review. B. CORRECT: Previous health survey results are an example of secondary data the nurse should review. C. Windshield surveys are a method of collecting direct data. D. Community forums are a method of collecting direct data. E. CORRECT: Health records are an example of secondary data the nurse should review

5. A nurse is working with a client who has systemic lupus erythematosus and recently lost her health insurance. Which of the following actions should the nurse take in the implementation phase of the case management process? A. Coordinating services to meet the client's needs B. Comparing outcomes with original goals C. Determining the client's financial constraints D. Clarifying roles of interprofessional team members

A. CORRECT: Coordinating services to meet the client's needs is an action the nurse should take in the implementation phase of the case management process. B. Comparing outcomes with original goals is an action the nurse should take in the evaluation phase of the case management process. C. Determining the client's financial constraints is an action the nurse should take in the assessment phase of the case management process. D. Clarifying roles of interprofessional team members is an action the nurse should take in the planning phase of the case management process

4. A nurse developing a community health program is determining barriers to community resource referrals. Which of the following factors should the nurse include as an example of a resource barrier? A. Costs associated with services B. Decreased motivation C. inadequate knowledge of resources D. Lack of transportation

A. CORRECT: Costs associated with services are an example of a resource barrier to community referrals. B. Decreased motivation is an example of a client barrier to community referrals. C. Inadequate knowledge of resources is an example of a client barrier to community referrals. D. Lack of transportation is an example of a client barrier to community referrals.

3. A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.

A. CORRECT: Door locks that are difficult to open are appropriate to reduce the risk of the client wandering outside without supervision. B. Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered. C. Cleaning supplies should be placed in locked cupboards. Marking the supplies with colored tape does not prevent the client's access to hazardous materials. D. CORRECT: Placing the client's mattress on the floor reduces the risk for falls out of bed. E. CORRECT: stairs should have adequate lighting to reduce the risk for falls.

1. A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply.) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. unwillingness to discuss the sexual assault

A. CORRECT: Sudden onset of phobic reactions is a characteristic of a silent rape reaction. B. Development of substance use disorder is a characteristic of a compound rape reaction. C. CORRECT: Increased anxiety during interview is a characteristic of a silent rape reaction. D. Reactivation of a prior physical disorder is a characteristic of a compound rape reaction. E. CORRECT: No verbalization of the sexual assault is a characteristic of a silent rape reaction.

1. A nurse is preparing an educational program on cultural perspectives in nursing. The nurse should include that which of the following factors is influenced by an individual's culture? (Select all that apply.) A. nutritional practices B. Family structure C. Health care interactions D. Biological variations E. Views about illness

A. CORRECT: culture is the beliefs, values, attitudes, and behaviors shared by a group of people and transmitted from generation to generation. The nurse should understand that nutritional practices are influenced by an individual's culture. B. CORRECT: culture is the beliefs, values, attitudes, and behaviors shared by a group of people and transmitted from generation to generation. The nurse should understand that family structure is influenced by an individual's culture. C. CORRECT: culture is the beliefs, values, attitudes, and behaviors shared by a group of people and transmitted from generation to generation. The nurse should understand that health care interactions are influenced by an individual's culture. D. Biological variations are physical, biological and physiological differences between races, and are not influenced by the beliefs, values, and attitudes of an individual. E. CORRECT: culture is the beliefs, values, attitudes, and behaviors shared by a group of people and transmitted from generation to generation. The nurse should understand that views about illness are influenced by an individual's culture.

5. A nurse at an urban community health agency is developing an education program for city leaders about homelessness. Which of the following groups should the nurse include as the fastest‑growing segment of the homeless population? A. families with children B. adolescent runaways C. intimate partner abuse survivors D. older adults

A. CORRECT: families with children are the fasting‑growing segment of the homeless population. B. Adolescent runaways are not the fastest‑growing segment of the homeless population. C. Intimate partner abuse survivors are not the fastest‑growing segment of the homeless population. D. Older adults are not the fastest‑growing segment of the homeless population.

4. A nurse is conducting a community assessment. Which of the following data collection methods is the nurse using when having direct conversations with individual members of the community? A. Key informant interviews B. Participant observation C. Focus groups D. Health surveys

A. CORRECT: informant interviews are direct conversations with individual community members for the purpose of obtaining ideas and opinions. B. Participant observation is observing formal or informal community activities and does not involve direct conversations with individual community members. C. Focuses groups are directed talks with a representative sample of a community, and do not involve direct conversations with individual community members. D. Surveys are specific questions asked in a written format and do not involve direct conversations with individual community members.

4. A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply.) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self‑esteem."

A. CORRECT: resentment is an emotion that can be associated with normal grief. B. CORRECT: Withdrawal is an emotion that can be seen with normal grief. C. CORRECT: somatic manifestations such as changes in sleep patterns can be associated with normal grief. D. Suicidal ideations are associated with maladaptive grieving. The client who is experiencing a distorted or exaggerated grief response can direct anger towards himself. The nurse should assess and monitor the client for thoughts of suicide or self‑injury. E. A client who is experiencing a maladaptive grief response commonly experiences a loss of self‑esteem and a sense of worthlessness. these findings are not associated with normal grief

3. A nurse is using the I Prepare mnemonic to assess a client's potential environmental exposures. Which of the following questions should the nurse ask when assessing for "a" in the mnemonic? A. "What do you like to do for fun?" B. "What year was your residence built?" C. "What jobs have you had in the past?" D. "What industries are near where you live?"

A. CORRECT: the "a" in the I‑Prepare mnemonic represents activities. The nurse should ask this question to determine hobbies and interests that might cause harm or expose the client to harmful substances. B. The nurse should ask this question to assess the first "r," which represents residence in the mnemonic. C. The nurse should ask this question to assess the second "P," which represents past work in the mnemonic. D. The nurse should ask this question to assess the first "e," which represents environmental concerns in the mnemonic.

3. A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (Select all that apply.) A. interpersonal relationships B. Culture C. Birth order D. religious beliefs E. Prior experience with loss

A. CORRECT: the client's interpersonal relationships are factors which influence the client's reaction to grief and ability to cope. B. CORRECT: the client's culture is a factor that influences the client's reaction to grief and ability to cope. C. Birth order is not a factor that influences grief and ability to cope. D. CORRECT: the client's religious beliefs are factors that influence the client's reaction to grief and ability to cope. E. CORRECT: the client's prior experience with loss is a factor that influences the client's reaction to grief and ability to cope.

5. A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of women's shelters. B. Encourage the client to participate in a support group for survivors of abuse. C. Implement case management to coordinate community and social services. D. Educate the client about the use of stress management techniques.

A. CORRECT: the greatest risk to this client is injury from intimate partner abuse; therefore, the priority action the nurse should take is to assist the client with the development of a safety plan that includes the identification of safe places to live. B. The nurse should encourage participation in a support group. However, this does not address the greatest risk to the client and is therefore not the priority nursing action. C. The nurse should implement case management. However, this does not address the greatest risk to the client and is therefore not the priority nursing action. D. The nurse should educate the client about the use of stress management techniques. However, this does not address the greatest risk to the client and is therefore not the priority nursing action.

2. A nurse is advocating for local leaders to place a newly approved community health clinic in an area of the city that has fewer resources than other areas. The nurse is advocating for the leaders to uphold which of the following ethical principles? A. Distributive justice B. Fidelity C. respect for autonomy D. veracity

A. CORRECT: the nurse is advocating for the leaders to uphold the ethical principle of distributive justice, which is the fair distribution of benefits and burden in society. B. The nurse is not advocating for the leaders to uphold the ethical principle of fidelity, which involves keeping commitments and following through with promises. C. The nurse is not advocating for the leaders to uphold the ethical principle of respect for autonomy, which is supporting the rights of individuals to determine and pursue personal health care goals. D. The nurse is not advocating for the leaders to uphold the ethical principle of veracity, which is the concept of telling the truth

3. An occupational health nurse is consulting with senior management of a local industrial facility. When discussing work‑related illness and injury, the nurse should include which of the following factors as physical agents? (Select all that apply.) A. noise B. Age C. Lighting D. Viruses E. Stress

A. CORRECT: the nurse manager should include noise as a physical agent when discussing work‑related illness and injury. B. The nurse manager should include age as a host factor when discussing work‑related illness and injury. C. CORRECT: the nurse manager should include lighting as a physical agent when discussing work‑related illness and injury. D. The nurse manager should include viruses as a biological agent when discussing work‑related illness and injury. E. The nurse manager should include stress as an outcome of psychological agents when discussing work‑related illness and injury.

3. A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape‑trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."

A. CORRECT: the nurse should administer prophylactic treatment for infections such as chlamydia according to the Centers for Disease Control and Prevention. B. The nurse must obtain informed consent to collect data that can be used as legal evidence. C. Manifestations of rape‑trauma syndrome are similar to posttraumatic stress disorder. D. The nurse should document subjective data, using the client's verbatim statements.

4. A newly hired occupational health nurse at an industrial facility is performing an initial workplace assessment. Which of the following information should the nurse determine when conducting a work site survey? A. Work practices of employees B. Past exposure to specific agents C. Past jobs of individual employees D. Length of time working in current role

A. CORRECT: the nurse should determine the work practices of employees when conducting a work site survey. B. The nurse should determine past exposure to specific agents when conducting an occupational health history on individual workers, not a work site survey. C. The nurse should determine past jobs of individual employees when conducting an occupational health history on individual workers, not a work site survey. D. The nurse should determine the length of time working in current role when conducting an occupational health history on individual workers, not a work site survey.

1. A nurse is preparing to conduct a windshield survey. Which of the following data should the nurse collect as a component of this assessment? (Select all that apply.) A. ethnicity of community members B. individuals who hold power within the community C. natural community boundaries D. Prevalence of disease E. Presence of public protection

A. CORRECT: the nurse should identify the ethnicity of the people visible in the community as a component of a windshield survey. B. Individuals who hold power are identified through formal and informal observations of community activities as a participant observer. C. CORRECT: the nurse should identify natural community boundaries as a component of a windshield survey. D. Prevalence of disease is incorrect. Disease prevalence is a component of secondary data and is identified through morbidity rates of the community. E. CORRECT: the nurse should identify the presence of public protection, such as police, fire, and animal control, as a component of a windshield survey.

1. A nurse manager at a community agency is developing an orientation program for newly hired nurses. When discussing the differences between community‑based and community‑oriented nursing, the nurse should include which of the following situations as an example of community‑based nursing? (Select all that apply.) A. a home health nurse performing wound care for a client who is immobile B. an occupational health nurse providing classes on body mechanics at a local industrial plant C. a school nurse teaching a student who has asthma about medications D. a parish nurse teaching a class on low‑sodium cooking techniques E. a mental health nurse discussing stress management techniques with a support group

A. CORRECT: the nurse should include wound care to an individual in the home as an example of community‑based nursing, which involves management of acute and chronic conditions in a community setting. B. The nurse should include teaching a class in the occupational setting as an example of community‑oriented nursing, which involves health care of individuals, families and groups to improve the collective health of the community. C. CORRECT: the nurse should include teaching a single student in the school setting as an example of community‑based nursing, which involves management of acute and chronic conditions in a community setting. D. The nurse should include teaching a class to members of a faith community as an example of community‑oriented nursing, which involves health care of individuals, families and groups to improve the collective health of the community. E. The nurse should include discussion with a group in the mental health setting as an example of community‑oriented nursing, which involves health care of individuals, families and groups to improve the collective health of the community.

5. A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. I felt the same when my mother died." D. "Do other members of your family also feel this way?"

A. CORRECT: this is a therapeutic response for the nurse to make. This response acknowledges the client's emotion and provides education on the normal grief response. B. This response offers advice, which is a nontherapeutic communication technique. C. This response minimizes the client's feelings and takes the focus away from the client, which are nontherapeutic communication techniques. D. This response takes the focus away from the client, which is a nontherapeutic communication technique.

5. A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?

A. CORRECT: this is an appropriate therapeutic response. Setting limits and the use of physical activity, such as walking, to deescalate anger is an appropriate intervention. B. "Why" questions imply criticism and will often cause the client to become defensive. C. This is a closed‑ended, nontherapeutic statement. D. The client is not ready to discuss this issue.

1. A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 3 are at greater risk for abuse" B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence toward the intimate partner."

A. Children younger than 3 years of age are at an increased risk for abuse. B. Substance use disorder increases the risk for violence. C. Vulnerable persons are an increased risk for violence when they try to leave the relationship. D. CORRECT: Pregnancy tends to increase the likelihood of violence toward the intimate partner.

1. A nurse is preparing a community health program on communicable diseases. When discussing modes of transmission, the nurse should include which of the following illnesses as airborne? A. Cholera B. malaria C. Influenza D. Salmonellosis

A. Cholera is waterborne illness. B. Malaria is a vector‑borne illness. C. CORRECT: influenza is an airborne illness. D. Salmonellosis is a foodborne illness.

1. A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over‑the‑counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donepezil." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

A. Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding. B. CORRECT: Donepezil slows the cognitive deterioration of Alzheimer's disease. C. Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease, prior to treatment. D. Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction. However, the client should not abruptly stop the medication without consulting a provider.

1. A nurse is talking to a client who asks for additional information about hospice. Which of the following statements should the nurse make? A. "Clients who require skilled nursing care at home qualify for hospice care." B. "One function of hospice is to provide teaching to clients about life‑sustaining measures." C. "Hospice assists clients to develop the skills needed to care for themselves independently." D. "A component of hospice care is to control the client's manifestations."

A. Clients who require skilled nursing care at home qualify for home health. B. Home health can provide teaching to clients about life‑sustaining measures. In hospice, medical care aimed toward a cure is stopped. C. Home health assists clients to develop the skills needed to care for themselves independently. D. CORRECT: controlling the client's manifestations of medical problems or the dying process and improving quality of life are components of hospice care.

2. A charge nurse is reviewing Kübler‑ross: five stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply.) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

A. Disequilibrium is the second stage of Bowlby's four stages of grief. B. CORRECT: the denial stage is when the client has difficulty believing a terminal diagnosis or loss. This is one of Kübler‑ross five stages of grief. C. CORRECT: The bargaining stage is when the client negotiates for more time or a cure. This is one of Kübler‑ross five stages of grief. D. CORRECT: the anger stage is when the client directs anger toward self, others, or objects. This is one of Kübler‑ross five stages of grief. E. CORRECT: the depression stage is when the client mourns and directly confronts feelings related to the loss. This is one of Kübler‑ross five stages of grief.

4. A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings. B. Maintain eye contact with the client. C. Move the client away from others. D. Tell the client that the behavior is not acceptable.

A. Encouraging the client to express her feelings is appropriate. However, it is not the priority action. B. Maintaining eye contact with the client is appropriate. However, it is not the priority action. C. CORRECT: the client's behavior indicates that he is at greatest risk for harming others. The priority action for the nurse is to move the client away from others. D. It is appropriate to tell the client that the behavior is not acceptable. However, it is not the priority action.

2. A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape‑trauma syndrome? (Select all that apply.) A. Genitourinary soreness B. Difficulties with low self‑esteem C. Sleep disturbances D. emotional outbursts E. Difficulty making decisions

A. Genitourinary soreness indicates a somatic reaction. B. Difficulties with low self‑esteem are an indication of a sustained and maladaptive emotional response beyond the initial reaction. C. Sleep disturbances indicates a somatic reaction. D. CORRECT: emotional outbursts indicate an expressed initial reaction of rape‑trauma syndrome. E. CORRECT: Difficulty making decisions indicates a controlled initial reaction of rape‑trauma syndrome.

4. A community health nurse is educating the public on the agents of bioterrorism. Which of the following agents should the nurse include as Category a biological agents? (Select all that apply.) A. Hantavirus B. typhus C. Plague D. tularemia E. Botulism

A. Hantavirus is a Category C biological agent. B. Typhus is a Category b biological agent. C. CORRECT: Plague is a Category a biological agent. D. CORRECT: tularemia is a Category a biological agent. E. CORRECT: botulism is a Category a biological agent.

2. A nurse is completing a needs assessment and beginning analysis of data. Which of the following actions should the nurse take first? A. Determine health patterns within collected data. B. Compile collected data into a database. C. Ensure data collection is complete. D. Identify health needs of the local community.

A. In order to determine health patterns within collected data, the nurse must take another action first. B. CORRECT: in order to adequately and appropriately analyze collected data, the nurse must first compile collected data into a database. C. In order to ensure data collection is complete, the nurse must take another action first. D. In order to identify health needs of the local community, the nurse must take another action first.

2. A school nurse is scheduling visits with a physical therapist for a child who has cerebral palsy. In which of the following roles is the nurse functioning? A. direct caregiver B. Consultant C. case manager D. Counselor

A. In the role of direct caregiver, a school nurse provides illness and injury care to children at school. B. In the role of consultant, a school nurse provides information to families, administrators, teachers, and parent‑teacher groups to encourage decisions that promote the health of the students. C. CORRECT: in the role of case manager, a school nurse coordinates comprehensive services for students who have complex health needs. D. In the role of counselor, a school nurse develops a trusting relationship with students and provides support on issues affecting their lives.

2. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of withdrawal? A. Decreased blood pressure B. Diaphoresis C. pinpoint pupils D. Bradycardia

A. Increased blood pressure is a manifestation of alcohol withdrawal. B. CORRECT: Diaphoresis is a manifestation of alcohol withdrawal. C. Dilated pupils are a manifestation of alcohol withdrawal. D. Tachycardia is a manifestation of alcohol withdrawal.

2. A nurse is caring for a client who is from a different culture than himself. When beginning the cultural assessment, which of the following actions should the nurse take first? A. Determine the client's perception of his current health status. B. Gather data about the client's cultural beliefs. C. Determine how the client's culture can affect the effectiveness of nursing actions. D. Gather information about previous client interactions with the health care system.

A. It is important for the nurse to determine the client's perception of his current health status. However, when conducting a cultural assessment, the nurse should perform a different action first. B. CORRECT: the nurse's first action when beginning a cultural assessment is to collect self‑identifying data about the client, including specific information about how the client's cultural beliefs influence family structure, food patterns, religious preferences, and health practices. C. While it is important for the nurse to determine how the client's culture can affect the effectiveness of nursing actions, the nurse must gather other information first. D. It is important for the nurse to gather information about previous client interactions with the health care system. However, when conducting a cultural assessment, the nurse should perform a different action first.

3. A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.) A. Lethargy B. Defensive responses to questions C. Disorientation D. Facial grimacing E. Agitation

A. Lethargy is more likely to be observed in a client who has depression. B. CORRECT: Defensive responses to questions are an assessment finding that can indicate that a client is in the preassaultive stage of violence. C. Disorientation is more likely to be assessed in a client who has a cognitive disorder. D. CORRECT: Facial grimacing is an assessment finding that can indicate that a client is in the preassaultive stage of violence. E. CORRECT: Agitation is an assessment finding that can indicate that a client is in the preassaultive stage of violence.

5. A community health nurse is determining available and needed supplies in the event of a bioterrorism attack. The nurse should be aware that community members exposed to anthrax will need access to which of the following medications? A. metronidazole B. Ciprofloxacin C. Zanamivir D. Fluconazole

A. Metronidazole is used to treat trichomonas's, skin infections, and septicemia. B. CORRECT: Community members exposed to anthrax will need access to ciprofloxacin. This medication is used for the prophylactic treatment of anthrax. C. Zanamivir is used to treat influenza. D. Fluconazole is used to treat candidiasis.

3. A nurse working in an emergency department is assessing a preschool‑age child who reports abdominal pain. When conducting a head‑to‑toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply.) A. abrasions on knees B. Round burn marks on forearms C. mismatched clothing D. abdominal rebound tenderness E. areas of ecchymosis on torso

A. Minor injuries, such as abrasions, on the arms and legs are common in this age group. B. CORRECT: Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse. C. Mismatched clothing is consistent with the child's developmental age. D. Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse. E. CORRECT: areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse.

3. A newly hired public health nurse is familiarizing himself with the levels of disaster management. Which of the following actions is a component of disaster prevention? A. outlining specific roles of community agencies B. identifying community vulnerabilities C. prioritizing care of individuals D. Providing stress counseling

A. Outlining specific roles of community agencies is a component of disaster preparedness. B. CORRECT: identifying community vulnerabilities is a component of disaster prevention. C. Prioritizing care of individuals is a component of disaster response. D. Providing stress counseling is a component of disaster recovery.

5. A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. Young adults are the typical victims of sexual assault." D. "The majority of rapists are unknown to the victims."

A. Rape is a crime of violence, aggression, anger, and power. B. CORRECT: alcohol and other substances are often associated with date or acquaintance rape. C. Individuals of all ages are affected by sexual assault and can be male or female. D. The majority of perpetrators are known to the vulnerable persons.

4. A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing an older adult to fall is an example of physical violence. C. Striking an intimate partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse.

A. Refusing to pay bills for a dependent is economic maltreatment, rather than neglect. B. CORRECT: Physical violence occurs when physical pain or harm is directed toward another individual. C. Striking an intimate partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent. D. Failure to provide a stimulating environment for normal development is neglect, rather than emotional abuse.

2. A home health nurse is discussing portals of entry with a group of newly hired assistive personnel. Which of the following locations should the nurse include as a portal of entry? (Select all that apply.) A. respiratory secretions B. Skin C. Genitourinary tract D. Saliva E. mucous membranes

A. Respiratory secretions are a portal of exit. B. CORRECT: skin is a portal of entry. C. CORRECT: the genitourinary tract is a portal of entry. D. Saliva is a portal of exit. E. CORRECT: mucous membranes are a portal of entry.

1. A nurse is creating partnerships to address health needs within the community. The nurse should be aware that which of the following characteristics must exist for partnerships to be successful? (Select all that apply.) A. Being a leading partner with decision-making authority B. flexibility among partners when considering new ideas C. adherence of partners to ethical principles D. Varying goals for the different partners E. Willingness of partners to negotiate roles

A. Shared power must exist for a partnership to be successful. B. CORRECT: flexibility must exist for a partnership to be successful. C. CORRECT: integrity must exist for a partnership to be successful. D. Shared goals must exist for a partnership to be successful. E. CORRECT: negotiation must exist for a partnership to be successful.

3. A community health nurse is developing an education program on substance use disorders for a group of adolescents. Which of the following information should the nurse include when discussing nicotine and smoking? A. Smoking is the fifth‑most preventable cause of death in the United States. B. Nicotine is a central nervous system depressant. C. Withdrawal effects from smoking are minimal. D. Tolerance to nicotine develops quickly.

A. Smoking is the leading preventable cause of death in the U.S. B. Nicotine is a central nervous system stimulant. C. Withdrawal effects from smoking are substantial and increase physical dependence. D. CORRECT: tolerance to nicotine does develop quickly.

5. A community health nurse is implementing health programs with several populations in the local area. In which of the following situations is the nurse using primary prevention? A. Performing a home safety check at a client's home B. teaching healthy nutrition to clients who have hypertension C. Providing influenza immunizations to employees at a local preschool D. implementing a program to notify individuals exposed to a communicable disease

A. The nurse is using secondary prevention when performing a home safety check. B. The nurse is using tertiary prevention when teaching healthy nutrition to clients who have hypertension. C. CORRECT: the nurse is using primary prevention when providing influenza immunizations to employees at a local preschool because the goal is to prevent the occurrence of disease or injury. D. The nurse is using secondary prevention when implementing a program to notify individuals exposed to a communicable disease.

2. A nurse in a long‑term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

A. The nurse should avoid statements that can be interpreted as argumentative or demeaning. B. The nurse should use positive, rather than negative, statements. C. Using a "why" question can promote a defensive reaction and does not reinforce reality. D. CORRECT: it is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner.

3. A nurse is planning a community health program. Which of the following actions should the nurse include as part of the evaluation plan? A. Determine availability of resources to initiate the plan. B. Gain approval for the program from local leaders. C. Establish a timeline for implementation of interventions. D. Compare program impact to similar programs.

A. The nurse should determine availability of resources to initiate the program as part of the assessment phase. However, when evaluating sustainability of the program, the nurse should determine whether resources are available for continuing the program. B. The nurse should gain approval for the program from local leaders as part of the preplanning phase because plans for the program should not move forward without adequate community support. C. The nurse establishes a timeline for implementation of interventions after determining and selecting the best strategies for meeting the program's goals and objectives. D. CORRECT: the nurse should include a comparison of program impact to similar programs as part of the evaluation plan. This comparison assists with determining the efficiency of the program.

4. A nurse is reviewing information about the local health department to prepare for an interview. Which of the following services should the nurse expect the local health department to provide? (Select all that apply.) A. managing the Women, Infants, and children program B. Providing education to achieve community health goals C. coordinating directives from state personnel D. reporting communicable diseases to the CDC E. licensing of registered nurses

A. The nurse should expect state departments of health to manage the Women, Infants, and children (WIC) program. B. CORRECT: Providing education to achieve community health goals is a component of identifying and intervening to meet health needs of the local community, which is a responsibility of local health departments. C. CORRECT: Funding for local health departments comes from local, state, and federal monies. Local health departments are responsible for coordinating directives issued from the state level. D. The nurse should expect state departments of health to report communicable diseases to the CDC. Local health departments report communicable diseases to the state department of health. E. The nurse should expect state boards of nursing to supervise licensure of registered nurses.

2. A nurse is reviewing the various roles of a community health nurse. Which of the following actions is an example of a nurse functioning as a consultant? A. advocating for federal funding of local health screening programs B. updating state officials about health needs of the local community C. facilitating discussion of a client's ongoing needs with an interprofessional team D. Performing health screenings for high blood pressure at a local health fair

A. The nurse should identify advocacy as a function of a change agent. B. CORRECT: updating officials about community health needs is an example of a nurse functioning as a consultant. Community health nurses serve as a consultant regarding the health care needs of individuals, families, and groups within the community served. C. The nurse should identify working with an interprofessional team as a function of a case manager. D. The nurse should identify performing health screening as a function of a caregiver.

3. A nurse is preparing an education program on disease transmission for employees at a local day care facility. When discussing the epidemiological triangle, the nurse should include which of the following factors as agents? (Select all that apply.) A. resource availability B. Ethnicity C. Toxins D. Bacteria E. altered immunity

A. The nurse should include resource availability as an environmental factor when discussing the epidemiological triangle. B. The nurse should include ethnicity as a host factor when discussing the epidemiological triangle. C. CORRECT: the nurse should include toxins as an agent when discussing the epidemiological triangle. D. CORRECT: the nurse should include bacteria as an agent when discussing the epidemiological triangle. E. The nurse should include altered immunity as a host factor when discussing the epidemiological triangle.

3. A case management nurse at an acute care facility is conducting an initial visit with a client to identify needs prior to discharge home. After developing a working relationship with the client, the nurse is engaging in the referral process. Which of the following actions should the nurse take first? A. Monitor the client's satisfaction with the referral. B. Provide the client information to referral agencies. C. Review available resources with the client. D. Identify referrals that the client needs.

A. The nurse should monitor the client's satisfaction with the referral as part of patient-centered care. However, another action must occur first in the referral process. B. The nurse should provide the client with information to referral agencies to enable the client to access needed services. However, another action must occur first in the referral process. C. The nurse should review available resources with the client to promote self-determination. However, another action must occur first in the referral process. D. CORRECT: using the nursing process, the first action the nurse should take at this point in the referral process is to assess client needs. After gathering client data, the nurse should identify referrals that the client needs and prioritize plans. This allows the nurse and client to focus on specific needs while moving forward in the referral process.

5. A school nurse is planning health promotion and disease prevention activities for the upcoming school year. In which of the following situations is the nurse planning a secondary prevention strategy? A. Placing posters with images of appropriate hand hygiene near restrooms B. routinely checking students for pediculosis throughout the school year C. implementing age‑appropriate injury prevention programs for each grade level D. Working with a dietitian to determine carbohydrate counts for students who have diabetes mellitus

A. The nurse should place posters with images of appropriate hand hygiene near restrooms as a primary prevention strategy. B. CORRECT: routinely checking students for pediculosis throughout the school year is a secondary prevention strategy the nurse can take. C. The nurse should implement age‑appropriate injury‑prevention programs for each grade level as a primary prevention activity. D. the nurse should work with the dietitian to determine carbohydrate counts for students who have diabetes mellitus as a tertiary prevention activity

4. A community health nurse is developing strategies to prevent or improve mental health issues in the local area. In which of the following situations is the nurse implementing a tertiary prevention strategy? A. providing support programs for new parents B. Screening a client whose partner recently died for suicide risk C. teaching a client who has schizophrenia about medication interactions D. Discussing stress reduction techniques with employees at an industrial site

A. The nurse should provide support programs for new parents as a primary prevention strategy. B. The nurse should screen a client whose partner recently died for suicide risk as a secondary prevention strategy. C. CORRECT: teaching a client who has schizophrenia about medication interactions is a tertiary prevention strategy. D. The nurse should discuss stress reduction techniques with employees at an industrial site as a primary prevention strategy.

4. A nurse is developing a community health education program for a group of clients who have a new diagnosis of diabetes mellitus. Which of the following learning strategies should the nurse include for clients who are auditory learners? A. showing informational videos B. Providing equipment to practice hands‑on skills C. supplying outlines for note‑taking D. facilitating small group discussions

A. The nurse should show informational videos as an appropriate learning strategy for clients who are visual learners. B. The nurse should provide equipment to practice hands‑on skills as an appropriate learning strategy for clients who are tactile‑kinesthetic learners. C. The nurse should supply outlines for note‑taking as an appropriate learning strategy for clients who are visual learners. D. CORRECT: facilitating small group discussions provides an opportunity for clients who are auditory learners to learn as they listen to information. This is an appropriate strategy for the nurse to include for this group.

4. A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do feel that you should not have been alone on the street at night?"

A. This response offers the nurse's opinion, which is a nontherapeutic communication technique. B. This responses indicates disapproval, which is a nontherapeutic communication technique. C. CORRECT: this response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings. D. This responses asks a "why" question, which is a nontherapeutic communication technique.

1. A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry." B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

A. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. B. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. C. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. D. CORRECT: this statement implies a threat and a lack of respect for another individual.

1. A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in order of occurrence. all steps must be used.) A. Developing awareness B. restitution C. shock and disbelief D. recovery E. resolution of the loss

Step 1: C. shock and disbelief is the first stage in Engel's five stages of grief. In this stage the client experiences a sense of numbness and denial over the loss. Step 2: A. Developing awareness is the second stage in Engel's five stages of grief. In this stage the client becomes aware of the reality of the loss resulting in intense feelings of grief. This begins within hours of the loss. Step 3: B. restitution is the third stage in Engel's five stages of grief. In this stage the client carries out cultural/religious rituals, such as a funeral, following the loss. Step 4: E. resolution of the loss is the fourth stage in Engel's five stages of grief. In this stage the client is preoccupied with the loss. This preoccupation gradually decreases over about a 12 month time period. Step 5: D. recovery is the fifth and final stage in Engel's five stages of grief. In this stage the client moves past the preoccupation with the loss and moves forward with life.

2. A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling. B. Request that other staff members remain close by. C. Move as close to the client as possible. D. Walk away from the client.

The nurse should not make demands of the client by insisting that he stop yelling. B. CORRECT: the nurse should request that other staff members remain close by to assist if necessary. C. Clients who are angry need a large personal space. D. The nurse should never walk away from a client who is angry. It is the nurse's responsibility to intervene as appropriate.

7) A school nurse notices bruises and scars on a child's body. The nurse suspects that the child is being physically abused. How should the nurse proceed with this information? a) As a health-care worker, report the suspicion to the Department of Health and Human Services. b) Check Jana again in a week and see if there are any new bruises. c) Meet with Jana's parents and ask them how Jana got the bruises. d) Initiate paperwork to have Jana placed in foster care

a) As a health-care worker, report the suspicion to the Department of Health and Human Services.

3) A battered woman presents to the ED with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. The priority nursing intervention is: a) Tending to the immediate care of her wounds b) Providing her with information about a safe place to stay c) Administering the prn tranquilizer ordered by the physician d) Explaining how she may go about bringing charges against her husband

a) Tending to the immediate care of her wounds

3. The nurse hears John, a client with a history of violence, yelling in the dayroom. The nurse observes his increased agitation, clenched fists, and loud, demanding voice. He is challenging and threatening staff and the other clients. The nurse's priority intervention would be to: a. Call for assistance. b. Draw up a syringe of prn haloperidol. c. Ask John if he would like to talk about his anger. d. Tell John if he does not calm down he will have to be restrained.

a. Call for assistance.

4. John, a client with a history of violence, has been hospitalized on the psychiatric unit. He becomes agitated and begins to threaten the staff and other clients. When all other interventions fail, John is placed in restraints in the seclusion room for his and others' protection. Which of the following are interventions for the client in restraints? (Select all that apply.) a. Check temperature and pulse of extremities. b. Document all observations. c. Explain to the client that restraint is his punishment for violent behavior d. Provide ongoing assessment and observation. e. Withhold food and fluid until client is calm and can be released from restraints.

a. Check temperature and pulse of extremities. b. Document all observations. d. Provide ongoing assessment and observation.

6. Which of these procedures is important in following up an episode of violence on the unit? (Select all that apply.) a. Document all observations and occurrences. b. Conduct a debriefing with staff. c. Discuss what occurred with other clients who witnessed the incident. d. Warn the client that it could happen again if he becomes violent.

a. Document all observations and occurrences. b. Conduct a debriefing with staff. c. Discuss what occurred with other clients who witnessed the incident.

10. Which of the following is true about aggression? (Select all that apply.) a. It is goal directed. b. Its aim is to do harm to a person or object. c. It has a requisite of intent. d. It energizes and mobilizes the body for self-defense

a. It is goal directed. b. Its aim is to do harm to a person or object. c. It has a requisite of intent.

1) Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department (ED) with her three small children. She tells the nurse her husband inflicted these wounds on her. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: a) "How often does he drink too much?" b) "It is not your fault. You did the right thing by coming here." c) "How many times has he done this to you?" d) "He is not a good husband. You have to leave him before he kills you."

b) "It is not your fault. You did the right thing by coming here."

8) Kate is an 18-year-old freshman at the state university. She was extremely flattered when Don, a senior star football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Kate to the emergency department. Kate says to the nurse, "It's all my fault. I shouldn't have allowed him to stop at the lake." The nurse's best response is: a) "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to stop at the lake." b) "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c) "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d) "You'll just have to see that he is arrested so he won't do this to anyone else."

b) "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."

5) Jana, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that Jana has numerous bruises on her arms and torso, in various stages of healing. She also notices some small scars. Jana's abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse suspects that: a) Jana is experiencing physical and sexual abuse. b) Jana is experiencing physical abuse and neglect. c) Jana is experiencing emotional neglect. d) Jana is experiencing sexual and emotional abuse.

b) Jana is experiencing physical abuse and neglect.

9) A young woman who has just undergone a sexual assault is brought into the ED by a friend. The priority nursing intervention would be: a) Help her to bathe and clean herself up. b) Provide physical and emotional support during evidence collection. c) Provide her with a written list of community resources for survivors of rape. d) Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

b) Provide physical and emotional support during evidence collection.

9. Which of the following assessment data would the nurse consider as risk factors for possible violence in a client? (Select all that apply.) a. A diagnosis of somatization disorder b. A diagnosis of bipolar disorder c. Substance intoxication d. Argumentative and demanding behavior e. Past history of violence

b. A diagnosis of bipolar disorder c. Substance intoxication d. Argumentative and demanding behavior e. Past history of violence

1. John, age 27, was brought to the emergency department by two police officers. He smelled strongly of alcohol and was combative. His blood alcohol level was measured at 293 mg/dL. His girlfriend reports that he drinks excessively every day and is verbally and physically abusive. The nurses give John the nursing diagnosis of Risk for Other-Directed Violence. What would be appropriate outcome objectives for this diagnosis? (Select all that apply.) a. The client will not verbalize anger or hit anyone. b. The client will verbalize anger rather than hit others. c. The client will not harm self or others. d. The client will be restrained if he becomes verbally or physically abusive.

b. The client will verbalize anger rather than hit others. c. The client will not harm self or others.

8. John and his girlfriend had an argument during her visit. Which behavior by John would indicate heis learning to adaptively problem-solve his frustrations? a. John says to the nurse, "Give me some of that medication before I end up in restraints!" b. When his girlfriend leaves, John goes to the exercise room and punches on the punching bag. c. John says to the nurse, "I guess I'm going to have to dump that broad!" d. John says to his girlfriend, "You'd better leave before I do something I'm sorry for."

b. When his girlfriend leaves, John goes to the exercise room and punches on the punching bag.

2) Sharon, a woman with multiple cuts and abrasions, arrives at the ED with her three small children. She tells the nurse her husband inflicted these wounds on her. In the interview, Sharon tells the nurse, "He's been getting more and more violent lately. He's been under a lot of stress at work the last few weeks, so he drinks a lot when he gets home. He always gets mean when he drinks. I was getting scared. So I just finally told him I was going to take the kids and leave. He got furious when I said that and began beating me with his fists." With knowledge about the cycle of battering, what does this situation represent? a) Phase I; Sharon was desperately trying to stay out of his way and keep everything calm. b) Phase I; a minor battering incident for which Sharon assumes all the blame. c) Phase II; the acute battering incident that Sharon provoked with her threat to leave. d) Phase III; the honeymoon phase where the husband believes that he has "taught her a lesson and she won't act up again."

c) Phase II; the acute battering incident that Sharon provoked with her threat to leave.

7. A client who has been in restraints is now calm. He apologizes to the nurse and says, "I hope I didn't hurt anyone." The nurse's best response is: a. "This is our job. We know how to handle violent clients." b. "We understand you were out of control and didn't really mean to hurt anyone." c. "It is fortunate that no one was hurt. You will not be placed in restraints as long as you can control your behavior." d. "It is an unpleasant situation to have to restrain someone, but we have to think of the other clients. We can't have you causing injury to others. I just hope it won't happen again."

c. "It is fortunate that no one was hurt. You will not be placed in restraints as long as you can control your behavior."

2. John, who was hospitalized with alcohol intoxication and violent behavior, is sitting in the dayroom watching TV with the other clients when the nurse approaches with his 5 p.m. dose of haloperidol. John says, "I feel in control now. I don't need any drugs." The nurse's best response is based on which of the following statements? a. John must have the medication, or he will become violent. b. John knows that if he will not take the medication orally, he will be restrained and given an intramuscular injection. c. John has the right to refuse the medication provided there is no immediate danger to self or others. d. John must take the medication at this time in order to maintain adequate blood levels.

c. John has the right to refuse the medication provided there is no immediate danger to self or others.

5. When it has been assessed that a client is in control and no longer requires restraining, how does the nurse proceed? a. The nurse removes the restraints. b. The nurse calls for assistance to remove the restraints. c. With assistance, the nurse removes one restraint. d. The nurse tells the client he will have to wait until the doctor comes in.

c. With assistance, the nurse removes one restraint.

4) A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: a) "I just can't believe you have decided to go back to that horrible man." b) "I'm just afraid he will kill you or the children when you go back." c) "What makes you think things have changed with him?" d) "I hope you have made the right decision. Call this number if you need help."

d) "I hope you have made the right decision. Call this number if you need help."

10) A woman who was sexually assaulted 6 months ago by a man with whom she was acquainted has since been attending a support group for survivors of rape. From this group, she has learned that the most likely reason the man raped her was: a) Because he had been drinking, he was not in control of his actions. b) He had not had sexual relations with a girl in many months. c) He was predisposed to become a rapist by virtue of the poverty conditions under which he was reared. d) He was expressing power and dominance by means of sexual aggression and violence.

d) He was expressing power and dominance by means of sexual aggression and violence.

6) A school nurse notices bruises and scars on a child's body, but the child refuses to say how she received them. Another way in which the nurse can get information from the child is to: a) Have her evaluated by the school psychologist. b) Tell her she may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse's questions. c) Explain to her that if she answers the questions, she may stay in the nurse's office and not have to go back to class. d) Use a "family" of dolls to role-play the child's family with her.

d) Use a "family" of dolls to role-play the child's family with her.