Psychosocial Quiz 1 (60 Q's)
A client tells the nurse, "My life isn't worth living. I'm ready for this to be over." Which nursing response uses restating as a therapeutic communication strategy? A. "Your life isn't worth living, and you're ready for this to be over?" B. "You must be going through a lot. Tell me more about how you're feeling." C. "From what I gather, it sounds like you're feeling hopeless right now?" D. "Can you share with me why you are feeling that life isn't worth living?"
A
The nurse is caring for a client admitted with a diagnosis of obsessive-compulsive personality disorder. Which behavior most concerns the nurse? A. Cleaning the room constantly without sleeping in the past 2 days B. Handwashing after touching every surface and after handshakes C. Going back to the room three or four times to make sure the doors are closed D. Feeling sad and hopeless about getting into college
A
During a mental health assessment, the client grimaces when speaking to the nurse, and begins to smile and giggle as the nurse leaves the room. Which nonverbal behavior is the client exhibiting? A. Facial expressions B. Body language C. Personal appearance D. Eye contact
A (NOT B: Body language includes posture, body movement, gestures and gait. Instead, when the client grimaces and smiles at the nurse, they are using facial expressions as a form of nonverbal communication.)
A client has been referred for psychiatric assessment related to severe postpartum depression. The psychiatrist has recommended inpatient psychiatric care. Which action is required by the nurse to verify and process the voluntary admission? A. The client needs to be informed about the recommendations, client rights, expectations of the inpatient experience and sign a consent for admission. B. A consent for voluntary admission may be signed by the spouse if the client refuses to sign the consent form. C. A written order for 72-hour hold psychiatric admission must be written by the psychiatrist or other qualified personnel because the client is a danger to self. D. The client needs to be educated that the initial psychiatric hold may be extended if there is no improvement in their condition.
A A voluntary psychiatric admission requires a signed consent from the client after they have received information about both their rights as a voluntary inpatient admission and what to expect during the hospitalization. Only if the client has diminished mental capacity with an appointed guardian, or is a minor, can someone else sign on behalf of the client. A client has the right to refuse a referral for voluntary inpatient psychiatric care.
The nurse performs a mental health assessment on a client. Which strategies are used by the nurse to convey active listening during the assessment? Select all that apply. A. Sitting in front of the client with an open posture B. Leaning in slightly when listening to the client share their stories C. Using well-placed silence throughout the discussion D. Focusing on the surrounding distractions E. Maintaining approximately 6 ft (2 m) distance from the client
A, B, C
The nurse is teaching a parent of an adolescent client who has a diagnosis of obsessive-compulsive disorder. Which description by the nurse to the parent is included in the teaching? Select all that apply. A. "Your child's disorder will interfere with activities of daily living." B. "Your child may be focused on perfection for all actions." C. "Doing repetitive handwashing and seeking extreme cleanliness are common actions." D. "Your child may demand constant attention and praise from others." E. "Your child may hurt someone and not express remorse."
A, B, C The nurse's statements reflect correct information about obsessive-compulsive disorder (OCD). Obsessive-compulsive disorder commonly interferes with the client's activities of daily living. A client with obsessive-compulsive disorder can be focused on perfection. Obsessions, such as extreme cleanliness, and compulsions, such as repetitive, frequent handwashing, are characteristics of OCD. Obsessions are intrusive and irrational thoughts, and compulsions are excessive urges to perform specific, unreasonable actions to relieve the anxiety caused by obsessions.
The nurse is providing health education to a client prescribed lorazepam. Which statements by the client to the nurse demonstrate effective teaching? Select all that apply. A. "Lorazepam carries a high risk of tolerance and addiction." B. "This medication is prescribed to treat my panic disorder." 18% C. "In higher doses, lorazepam can help with insomnia." 22% D. "It is best if I take this medication for only a few weeks." 4% E. "Lorazepam should not be taken with alcohol."
A, B, C, E NOT D: It is not correct that lorazepam can only be taken for a few weeks. Many clients take benzodiazepines long-term as a treatment for anxiety, panic disorders, insomnia, and seizures.
Which barriers to therapeutic communication with a client may be encountered by the nurse? (Select all that apply) A. Client with impaired cognition or intellectual development B. High level of emotions and levels of stress in the client C. The biological age of the client D. Socioeconomic status E. Language spoken by the client
A, B, C, E NOT Option D: Therapeutic communication is used by nurses in a healthcare setting to focus on the physical and emotional well-being of the client. Challenges in communication can impede the effective and therapeutic exchange of information. These challenges can include the client's level of cognition, emotional state, stress levels, developmental level, age, and language spoken. The client's socioeconomic status is not considered a factor that poses a challenge.
The nurse is caring for a client during the early morning nursing rounds when the client states, "I cannot forgive myself for what I have become. I'd rather die than live like this." Which nursing intervention is included in this client's plan of care? Select all that apply. A. Collaborate with the client in making a contract for no self-harm. B. Ask if the client has a plan to end their life. C. Respect the client's rights to autonomy and privacy. D. Ask the client about any suicidal thoughts. E. Thank the client for sharing and promise the client confidentiality.
A, B, D Correct answer A: It is the nurse's responsibility to provide a safe and therapeutic environment and ensure that the client does not harm themselves or others. The nurse may propose a contract with such clients that states the clients will not harm themselves or will call for help if they have thoughts of self-harm or suicide. Correct answer B: When a client expresses a desire to harm or kill themselves, the nurse should further assess the client's risks by asking if the client has a plan for how to kill themselves. Having a plan in place elevates the client's risk of suicide and will likely require constant 1:1 observation to prevent self-harm. Correct answer D: The nurse should assess the client's suicidality directly. The client may have passive thoughts of death or active thoughts of ending their own life. Understanding the client's thought process allows the nurse to assess the risk of suicide. The nurse should ask the client about this directly after establishing a therapeutic, trusting relationship if possible. Option C: If the client expresses thoughts of self-harm or suicide, the client should not be left alone. The nurse should further assess the client's suicidal thoughts and whether there is a plan to commit suicide. It may be necessary to provide 1:1 observation to keep the client safe and prevent opportunities for self-harm or suicide. Option E: It is important to maintain a therapeutic relationship to stress confidentiality and thankfulness. If the nurse becomes aware of a situation that puts the client at risk, then the confidential conversation cannot be promised. The nurse has a duty to report these statements and take appropriate interventions to keep the client safe.
The nurse is assessing a client admitted to the psychiatric unit to treat obsessive-compulsive disorder. Which sign or symptom does the nurse recognize as associated with this disorder? Select all that apply. A. The client washes their hands repeatedly during the day. B. The client states, "I can't drive because I'll get into an accident and die." C. The client states, "Someone is following me and wants to hurt me." D. The client organizes belongings in an orderly, symmetrical pattern. E. The client displays extreme distress if the flatware cutlery is not facing the wall.
A, B, D, E
The nurse manager evaluates the knowledge of the newly hired nurse about the five-step nursing process. Which statements by the nurse indicate an understanding of the five-step ADPIE, nursing process? Select all that apply. A. "It is a multi-step process where I am required to use critical thinking." B. "The assessment data that I collect is based on subjective and objective data." C. "I should always document at the end of the shift, so I can spend more time with the client." D. "I will inspect all diagnostic and laboratory values, and physical and behavioral findings." E. "I can also ask questions to family members if the client is unable to provide information."
A, B, D, E
The nurse is caring for a client with generalized anxiety disorder. Which behavior does the nurse recognize as a behavioral adaptation associated with the anxiety? Select all that apply. A. Eating habits consist of unhealthy choices. B. Drugs or alcohol is used to self-medicate. C. The client commits serious crimes without remorse. D. The client exhibits nail-biting behavior. E. The client has episodes of inappropriate laughing.
A, B, D, E Correct answers A, B, D, and E: A client with general anxiety disorder will activate behavioral symptoms to relieve their anxiety. These strategies may become behavioral maladaptations that ease some stress and pressure the client experiences. Some maladaptive behaviors include binge-eating, nail-biting, inappropriate laughing or crying, daydreaming, and repetitive yawning. Clients may also attempt self-medication to relieve their anxiety, using over-the-counter and recreational drugs. These behaviors may lead to substance abuse. Option C: When a client commits a serious crime without remorse, the client is displaying a behavior associated with antisocial personality disorder, not an anxiety disorder. This behavior is not a coping mechanism; instead, it is a symptom of the disorder.
The nurse is performing medication reconciliation with a client. The client recently began taking lorazepam 2 mg BID PRN for anxiety. Which statements by the client indicate a need for further instruction? (Select all that apply) A. "I always wait an hour after taking my lorazepam before I have a glass of wine." B. "I tell my healthcare provider about most of the medications I take." C. "I only take the lorazepam when I'm feeling anxious." D. "I sometimes take oxycodone with my lorazepam." E. "I have to be careful with my lorazepam because it can cause sedation."
A, B, and D Benzodiazepines are sedatives and can cause respiratory depression and fatality when combined with other central nervous system (CNS) depressants such as alcohol and opioid medications. The client's belief that it is safe to drink alcohol an hour after taking lorazepam is incorrect. The client will also need to be educated not to take lorazepam with oxycodone. The client does not understand the importance of ensuring the healthcare provider has a complete and accurate medication list. The healthcare provider needs to be aware of changes in a client's medications to help prevent medication interactions and educate the client about potential side effects. NOT Options C and E: Benzodiazepines carry a risk of respiratory depression, tolerance, and dependency. The client demonstrates understanding that lorazepam should only be taken as needed. The client also understands that lorazepam is a CNS depressant, and that care must be taken to prevent over-sedation.
The nurse is caring for a client diagnosed with borderline personality disorder. When assessing the client for suicidal risk, which question will the nurse ask? Select all that apply. A. "How often have you felt depressed or hopeless?" B. "Do you think that someone is out to get you?" C. "Have you ever considered hurting yourself?" D. "Are you considering killing yourself at this time?" E. "Has anyone ever tried to harm you?"
A, C, D
The nurse is reviewing medications with a client who has a diagnosis of post-traumatic stress disorder. Lorazepam 0.5 mg twice daily is one of the prescribed medications. Which statement indicates the client's understanding of the medication? Select all that apply. A. "I'm glad I can still work while taking this medication." B. "I will limit my alcohol consumption while taking this medication." C. "When instructed to do so, I can start tapering off the medication." D. "I am aware that I could have diarrhea or constipation." E. "I'll take the medication when I am in a stressful situation."
A, C, D
The nurse is about to administer diazepam. Which client will benefit from this medication? Select all that apply. A. A client who has been experiencing panic attacks in crowds. B. A client who is experiencing excessive bleeding after giving birth. C. A client experiencing alcohol withdrawal. D. A client who has seizures. E. A client who has been depressed for the last two months.
A, C, D Diazepam is an anti-anxiety medication useful in treating anxiety and panic disorders. Anti-anxiety drugs have a sedative/hypnotic effect which can calm the client in the instance of a panic attack. A client experiencing alcohol withdrawal can benefit from benzodiazepines such as diazepam. These drugs potentiate GABA in the brain which returns the brain into a relaxed state after the disarray caused by withdrawal from alcohol. Anti-anxiety medications depress the central nervous system, which is helpful in clients with seizures. Diazepam is often given rectally in emergency situations to treat seizures. Option B: Diazepam is an anti-anxiety medication and would not be the correct medication used to treat bleeding. Option E: Anti-anxiety drugs cause drowsiness, lethargy, and mental slowness, which are already present in a person with depression. Anti-anxiety medications have the potential to worsen depression. Administration of diazepam is not an appropriate choice to treat the client's depression.
A client diagnosed with generalized anxiety disorder is prescribed alprazolam 0.25 mg TID. Which instructions will the nurse give the client? Select all that apply. A. "Do not take this medication with alcohol." B. "Do not take this medication close to bedtime." C. "Do not drive or operate heavy machinery while taking this medication." D. "Do not take this medication if you are not feeling anxious." E. "Do not take this medication with an opioid medication."
A, C, E Alprazolam is a medication within the drug class benzodiazepines. These medications are classified as sedative-hypnotics. Benzodiazepines cause central nervous system (CNS) depression, including respiratory depression. If taken in addition to other CNS depressants such as alcohol or opioid medications, they can slow the respiratory rate significantly which can be fatal. Benzodiazepines can also cause dizziness and drowsiness and driving or operating heavy machinery is not advised especially when first starting the medication. NOT Option B: Sedative hypnotic medications such as alprazolam are sedating and can be taken close to bedtime. They are often prescribed as sleep aids to treat insomnia. NOT Option D: The prescription is written as scheduled three times per day (TID). Therefore, the client should take the medication even if they are not currently experiencing anxiety. Benzodiazepines such as alprazolam have the potential to cause physical dependence and these medications need to be tapered before being discontinued. Skipping doses without discussion with a healthcare provider could lead to withdrawal, seizure, or death.
The nurse is interviewing a client with a diagnosis of post-traumatic stress disorder. Which statement by the nurse is stated during the interview? Select all that apply. A. "Here is a summary of what was discussed." B. "Let's explore these unacceptable emotions." C. "I am glad to work with you to help you feel better." D. "There haven't been any nightmares, right?" E. "Have you had any thoughts about suicide?"
A, C, E Correct answer A: Summarizing information provided by a client is an appropriate method of communication when interacting with a client. This allows the nurse to demonstrate an understanding of the information. It also gives the client the opportunity for clarification. Correct answer C: The nurse's statement is appropriate. The nurse is communicating to the client that the nurse is there to help the client to feel better. Offering to work together with a client provides hope and lets the client know that they are not alone. Correct answer E: It is appropriate and crucial for the nurse to ask a client about thoughts of suicide. Suicide is commonly associated with PTSD and must be addressed to prevent a fatal outcome. The optimal approach to address suicide is to administer an evidence-based screening tool. However, asking a direct question to elicit this pertinent information is acceptable when time is limited and a therapeutic relationship is already established. Option B: The nurse must not accuse a client of not being able to control emotions. Rather, the nurse should be understanding and caring in a non-threatening manner. The nurse should avoid judgmental statements such as this. Option D: Nightmares are symptoms of PTSD. However, the nurse worded the question as a leading question with a suggestive answer. This type of question can influence a client's response and cause them to provide inaccurate information. Therefore, the nurse should word questions that focus on open-ended responses when possible and make sure the questions don't suggest a specific response.
The nurse assesses a young adult client who was recently prescribed alprazolam 0.25 mg TID PRN. Which client statements indicate that the desired outcome of this medication has been achieved? Select all that apply. A. "I was able to concentrate in class today." B. "I have been thinking a lot about the big exam I have coming up." C. "I had a good night's sleep and woke up in time for class." D. "I always worry that something might happen to my dog when I'm not home." E. "I always feel calm most of the day."
A, C, and E: Alprazolam is a medication within the drug class benzodiazepines. These medications are used to treat generalized anxiety disorder (GAD), panic disorder, and insomnia, among other conditions. The client's report of being able to concentrate in class, sleep through the night, and feel overall calm throughout the day indicates that the alprazolam has been successful at reducing the client's anxiety symptoms. NOT Option B: Rumination is the concept of thinking the same thoughts repeatedly and can be associated with GAD. While thinking about a deadline or exam is common, perseverating on these thoughts indicates that the alprazolam may not be working well enough for this client. NOT Option D: The client demonstrates persistent worry about many things, which is characteristic of GAD. This disorder is characterized by excessive, persistent, and unrealistic worry about everyday things. Benzodiazepines are used when an immediate reduction of these symptoms is desired; however, the client's ongoing worry is an indication that the alprazolam may not be effective in this case.
During a group activity, the nurse notices one of the clients is sitting in a chair, tapping their feet rapidly and clenching and unclenching their fists. The client is not participating in the activity or engaging in conversation with others. Which actions does the nurse perform to address safety within the group setting? Select all that apply. A. Scan the room for objects that the client could use to cause injury to others in the room. B. Ask the client to step out of the meeting and go to their room until they are more willing to participate. C. Announce to all that the activity will need to be terminated early. D. Escort the client out of the room to a quieter area, identify the behaviors and ask the client to share feelings during the activity. E. Escort the client out of the area and remind the client that participation is required in group activities to avoid loss of privileges.
A, D
The nurse is ready to prepare and provide medication to a group of clients. Which actions by the nurse demonstrate an understanding of professional liability during the medication administration? Select all that apply. A. Watching the client take the medication provided, and ensuring the medication has been swallowed and not pocketed in the cheek B. Asking the art therapist to take the medication to a client who has moved into the day room for an art activity C. Documenting the administration of the medication at the time of preparation, to keep track of which medications have been prepared. D. Asking the client to state their full name and checking the wristband prior to administering the medication E. Insisting the client admitted involuntarily takes the medication that was prescribed, despite the client's objections.
A, D (NOT Option C: Documentation of medications administered should only be done after the administration of the medication. Pre-documentation of medication is a violation of the nursing standards of care.)
A client who has a diagnosis of panic disorder describes the progress with inpatient treatment to the nurse. Which statement by the client indicates that the outcomes successfully meet the nursing goals? Select all that apply. A. "When I feel an attack is starting, I practice mindfulness." B. "When I feel a panic attack starting, I don't fight against it." C. "I have learned to accept the panic feelings and work through them." D. "I take my prescriptions and participate in group psychotherapy." E. "A small amount of alcohol helps me cope better with the attacks."
A, D NOT Options B, C, and E: These statements do not reflect successful treatment outcomes. The client who verbalizes that the only way they are managing the panic attack is to let it happen, just accept it, or simply get through it is not showing any positive results for effectively managing their anxiety using healthy strategies and newly learned skills. The client is exhibiting maladaptive behavior by using alcohol and substances to cope with their anxiety.
The nurse is admitting a new client to the psychiatric unit. As part of the custodial care for the client, which actions does the nurse perform? Select all that apply. A. Showing the client where their sleeping area and clothes storage is B. Completing the admission intake form for this client within 24 hours of admission C. Initiating an individualized plan of care for the client D. Assessing the client for signs of anxiety or attempts to self harm E. Administering prescribed medications
A, D, E Correct answer A: Orienting the client to the unit and the personal area is a custodial duty. This may be a new environment for the client and is different from an acute care hospital admission. At the time of admission, the client needs to be oriented to the environment along with the rules and any responsibilities of the client within the unit. Correct answer D: The nurse needs to continually assess the client's mood and thought process during the admission orientation process and throughout their stay. Custodial care involves creating a safe environment and ensuring client safety. Correct answer E: Medication administration is an important custodial duty of the nurse along with educating the client on the purpose of the medication, assessing the effect and any side effects. If this medication will be part of the treatment plan after discharge, it is especially important that the nurse educates the client on the importance of continuing the medication to avoid a possible relapse. Options B and C: Completing the admission intake form within the policy time frame set by regulations and the facility and initiating an individualized plan of care are all duties expected of the nurse. These are regulatory requirements
A client was admitted into a mental health care facility after a suicide attempt. The client tells the nurse, "I know that I made a contract not to hurt myself, but I do not know how to survive this situation. I feel so alone." Which response by the nurse is best? A. "By signing the contract, you promised not to harm yourself. Why has this changed?" B. "What has helped you with these feelings of hopelessness and loneliness in the past?" C. "Group therapy sessions will make you feel less isolated. Would you like to try them?" D. "Let's revise the contract and make it more personal for you so it's not so easy to break."
B
The nurse assesses a client with a diagnosis of anxiety who has come to the clinic to replenish their prescription of diazepam. Which statement by the client indicates the need for immediate nursing intervention? A. "I smoked salmon and a dried fruitcake for lunch yesterday." B. "I felt a bit stressed, so I had two glasses of wine last night." C. "I'm not sleeping well because I just got a new job." D. "I finally started going to the gym to work out last week."
B
The nurse is caring for a client who is exhibiting a panic attack. Which statement by the nurse to the client is therapeutic? A. "This is a short-term problem, and you will feel better before you leave." B. "Let's try taking slow, deep breaths. I'll stay with you until you feel better." C. "Did you keep the instructions that were given on how to stop these attacks?" D. "I'll give you some time to calm down. Then I'll come back and we can talk."
B
The nurse is caring for a client with symptoms of hopelessness, anhedonia, and social isolation. During early morning rounds, the client tells the nurse, "If I don't get to do so, please tell my mother I love her very much." Which nursing action is most appropriate for the nurse to perform? A. Offer the client a cell phone to contact their parent. B. Assess the client's safety and screen for suicidal thoughts. C. Suggest that the client interact with and participate in group therapy. D. Distract the client with a positive, lighthearted conversation.
B
The nurse is caring for clients with a panic disorder. Which situation involving a client does the nurse recognize as reflecting the defense mechanism of regression? A. A client who states, "I don't have anxiety; I feel perfectly normal." B. A client who states, "I need to find some cigarettes and start smoking again." C. A client who yells at another person, saying, "You are a total loser!" D. A client who states,"I eat more because my metabolism is higher and I need more food."
B
The nurse is caring for several clients and is providing care in an environment with limited time and staff resources. Which action by the nurse during this shift is considered malpractice? A. Failing to provide signed release forms at admission B. Administering an increase in medication that results in respiratory failure C. Advising a client that nursing instructions will be provided later because of time constraints D. Failing to provide a needed assistive device for an assigned client who fell after walking but was uninjured
B
The nurse is conducting an interview with a client who mentions feeling sad and reports weight loss, insomnia, and inability to work for the past three weeks. Which question does the nurse ask next? A. "Are you sad because you have lost weight?" B. "Can you tell me more about feeling sad?" C. "Do you feel more sad when you are in your bedroom?" D. "Are you worried about paying your bills?"
B
The school nurse is assessing an adolescent who reports feeling sad and helpless. Both of the client's parents received a diagnosis of COVID-19 and were admitted to the intensive care unit. The client is living with relatives. Which nursing action reinforces coping skills for this client? A. Going with the client during visits with the parents B. Arranging crisis referrals for the client and family C. Advocating for the child to have time alone at school D. Spending time with the client on the nurse's days off
B
During discharge teaching, the nurse is communicating with a client while looking down at the client, with the arms crossed, and gazing toward the doorway. Which form of communication is the nurse exhibiting? A. Ineffective symbolic communication B. Ineffective nonverbal communication C. Effective therapeutic verbal communication D. Therapeutic communication
B (Symbolic communication embodies verbal and nonverbal symbols and icons.)
A school-age client with a diagnosis of anxiety disorder visits the school nurse after being involved in an altercation. When asked about the altercation, the client states, "I did not fight with anyone. I was just eating my lunch and talking to my friends." Which type of ego-defense mechanism is the client using to relieve anxiety? A. Compensation B. Denial C. Displacement D. Projection
B Correct answer B: When the client with an anxiety disorder does not accept that the situation is real, as in this scenario, this type of ego-defense mechanism is known as denial. In this scenario, the client's defense mechanism is to relieve the anxiety about the consequences of the altercation. The defense mechanism is a psychological strategy used unconsciously to protect the client from anxiety caused by unacceptable thoughts or feelings. Option A: Compensation is hiding a weakness by developing a new skill to focus on. A client may compensate for an anxiety about being less wealthy than their peers by working extra hard at their job and excelling. Option C: Displacement is used to relieve anxiety and is characterized by taking out the anxiety on a person who is not the cause of the feelings. A client may displace their anxiety about a failing relationship by physically abusing a pet. Option D: Projection is when a client identifies their own unacceptable thoughts or feelings in someone else. A client may display projection when they are very upset about a loss, and instead of recognizing their own grief, they see grief in everyone that they meet.
The nurse teaches a newly admitted hospitalized client about the rules and regulations of the Health Insurance Portability and Accountability Act (HIPAA). The nurse correctly teaches the client that HIPAA is which type of set of rules and regulations? A. Common law B. Federal statutory law C. Regulatory law D. Standards of care
B HIPAA is a federal statutory law that protects client health information from disclosure without consent or knowledge. Statutory law is a law that is passed by a legislative body. HIPAA was passed by the 104th US Congress and signed by President Clinton in 1996. Option A: HIPAA is a federal statutory law, not common law. Common law is a law that results from prior legal decisions and is passed on legal precedent, whereas HIPAA was passed by a legislative body. Option C: A regulatory law is established by regulatory agencies, such as the Board of Nursing at the state level. HIPAA is statutory law, not regulatory law. Nursing practice is governed by legal concepts and principles that regulate credentialing and standards of nursing practice in these standards of care. Option D: Standards of care are developed according to state and federal rules and laws that govern nursing practice. They are established at a national level, such as by the American Nurses Association, or at a state level. Standards of care incorporate legal, ethical, and professional standards for the safe and effective delivery of nursing care.
The nurse manager is observing a newly graduated nurse who is caring for 4 hospitalized clients. Which action by the newly graduated nurse does the nurse manager identify as an act of negligence in nursing? A. The nurse does not report to the healthcare provider that the client is experiencing pain postoperatively. B. The nurse does not monitor a client's vital signs as prescribed after the client received anticoagulant treatment for stroke. C. The nurse postpones a client's physical therapy treatment to schedule the prescribed magnetic resonance imaging scan instead. D. The nurse delegates taking vital signs of a stable client to a UAP without providing supervision.
B It is important that the nurse monitors a client experiencing an acute stroke after acute anticoagulant treatment according to standards of care and evidence-based practice. If the nurse does not follow the prescribed monitoring of the client's vital signs, it is an act of negligence that can result in mortality and morbidity. Option A: The nurse does not have to report to the healthcare provider that a client is in pain postoperatively unless there are other signs and symptoms of complications or a level of pain that is not expected postoperatively. Typically, pain is expected postoperatively, and the health care provider prescribes a PRN medication to control pain after surgery. Option C: It is not considered negligence when the nurse postpones a physical therapy treatment to schedule a magnetic resonance scan. The nurse is simply organizing the client's schedule to ensure all of their needs are met. Option D: The nurse can delegate responsibilities to a UAP within the scope of practice of the UAP. It is within a UAP's scope of practice to assess the vital signs of a stable client without the supervision of the nurse.
The school nurse identifies a school-aged client who is experiencing an adverse childhood event in the home. After an extensive assessment of the client's home, which situation does the nurse identify as an associated protective factor? A. The child takes care of two younger siblings. B. The child attends a youth group meeting each week. C. The child's parents divorced when the client was a toddler. D. The child reads alone in the library during lunchtime.
B Protective factors positively influence mental well-being. These include having a sense of faith, stable family support, a trusted adult to confide in, reliable friendships, and a strong sense of self-sufficiency, as well as participation in clubs or sports.
The nurse is caring for an adolescent client who has a diagnosis of anxiety disorder. The client's parents report that the disorder started during a pandemic, when schools were closed. Which factor has an additional influence on the client's mental well-being? A. The parents are both working from home full-time. B. Teaching was conducted with online virtual classes. C. The routine family summer vacation was canceled. D. More time was spent with siblings than with parents.
B The switch to online learning is considered a disruption to social and emotional learning environments, especially for adolescents who are discovering their identities. This difficulty in trying to connect with others through online learning can lead to the development of mental health disorders.
A client with panic disorder suddenly reports chest pain, difficulty breathing, tingling of their hands, and nausea. The nurse observes trembling, labored respirations, and sweating. The client states, "I feel as if I'm going to die!" Which statement does the nurse recognize that best explains this event? Select all that apply. A. "These symptoms are always associated with cardiac ischemia." B. "Panic attacks are caused by increased levels of norepinephrine." C. "Psychotherapy is an effective treatment for this disorder." D. "Medications such as sedatives can reduce symptoms." E. "Panic attacks are related to high testosterone levels."
B, C
The nurse manager has appointments with 5 nurses who care for clients in a long-term facility. During each individual meeting, the nurse manager discusses negligence recently caused by a nursing action of each nurse. Which nursing actions by these nurses constitute malpractice? Select all that apply. A. Forgetting to document a client's allergy in the medical record when no allergic reaction occurred. B. Failing to attend to a bed alarm, which resulted in a client falling out of bed and breaking their pelvis. C. Not providing protective covering for a client and leaving hot packs on too long when the client has diminished sensation, resulting in second-degree burns. D. Making a lengthy personal phone call during a shift, which delays a client's discharge. E. Lying to a unit manager about an absence to avoid missed pay.
B, C Option A: Forgetting to document a client's allergy in the medical record is negligence. If no allergic reaction occurred and there was no injury or complication, it is not considered malpractice. Option D: Making a lengthy personal phone call during a shift that delays a client's discharge does not constitute malpractice because it did not result in injury. It is an act of disrespect and a violation of company policy, but it is not malpractice. Option E: Lying is against a code of ethics, but it is not malpractice. This action had no malicious intent that caused harm and did not cause injury or a complication, therefore, is not considered malpractice.
The nurse meets a newly admitted client in the inpatient psychiatric unit. The role of the nurse, in collaboration with the multidisciplinary team, includes which functions? Select all that apply. A. Assumes the primary role for determining placement and resources needed after discharge from the psychiatric unit B. Collects and documents data from the client and family members, as well as responses to interventions and treatments C. Develops and implements a comprehensive plan of care for the client D. Evaluates the client's response and progress toward meeting goals that are anticipated by the multidisciplinary team E. Educates the client that the health team will determine activities and medications that best support them in recovery.
B, C, D Correct answer B: The nurse is responsible for collecting a comprehensive set of data or information about the client to be shared with the multidisciplinary team. This information is obtained directly from the client, and when possible, from family members who know the client well. Since the nurse spends the most amount of time with the client, the nurse will also observe and document how the client responds to the interventions that were created. Correct answer C: The nurse is an integral part of the team that reviews data and creates a comprehensive plan of care for the client's recovery. In addition to nursing specific interventions, the nurse facilitates the goals and interventions of the other healthcare team members. Correct answer D: The comprehensive plan of care is reviewed and revised on a regular basis based on the client's response. Goals and interventions are updated and revised based on the client's ability to meet the expected progress. Option A: The primary role of discharge planning and coordination of post discharge resources following an inpatient psychiatric admission is a primary role of the care manager and/or the social worker. The nurse supports the efforts by gathering data and sharing information that may impact the discharge planning process. Option E: The client is the most important person on the multidisciplinary team. The client has valuable insights for how interventions have worked previously. The client needs to be a partner within the multidisciplinary team when setting goals, treatments, and interventions to reach the goals. A plan should not be created that ignores or devalues the client's insights.
The nurse provides teaching to the parents of an adolescent client. The client's potential diagnosis is a generalized anxiety disorder. Which statement by the nurse is included in the teaching? Select all that apply. A. "This is a rare mental health disorder that affects a small part of the population." B. "If the anxiety is unresolved, the sense of fear can affect the activities of daily living." C. "If your child's moderate anxiety is left untreated, it can progress to an anxiety disorder." D. "Your child's brain chemistry may be a contributing cause of their anxiety disorder." E. "Evidence shows that a genetic association is present with anxiety disorders."
B, C, D, E
Which statements by a client indicate the nurse has a duty to violate privileged communication between the client and nurse and share the statements with authorities? Select all that apply. A. "When I get home, I am going to make my wife move out. She is the cause of my problems. If it were not for her, I would not be having any issues and would not be here." B. "If I ever see the doctor that forced me to come for a psychiatric evaluation, he better watch out. I was just kidding about trying to kill myself. I will have my gun with me, and he will pay for ruining my life." C. "Those people are ruining the country. I wish someone would make them shut up, and we would all be in a better place." D. "My mother refuses to allow me to eat for days if I bring home a C on a test because I have dishonored the family. It is hard to study when hungry." E. "I know where the key is to the gun cabinet. I may take the gun to school if the teacher picks on me again and the kids laugh at me."
B, D, E
The nurse is caring for a client who has retired from the music industry and is under hospice end-of-life care. The client asks the nurse, "Is there anything else besides traditional medical treatment to help me cope with my anxiety?" Which responses by the nurse are correct? Select all that apply. A. "No other treatments can help at this time because of your prognosis." B. "I can show you how to use guided imagery to help you relax." C. "I can arrange for a psychologist to evaluate you for a behavioral modification program." D. "I can ask the health care provider about this, and perhaps a new drug can be prescribed to help you relax." E. "I can help you identify the genre and types of music that you have enjoyed in the past to find music that may promote relaxation."
B, E
A new graduate is assigned to the psychiatric care clinic. During orientation, the supervisor explains the continuum of mental health. Which statement best matches the nurse's role in maintaining a client's mental health? A. "I will assess for mental illness in a specific group of people with risk factors." B. "I understand that mental health is the responsibility of counselors and psychiatrists." C. "I will help identify resources that aid the client in reaching optimal mental health." D. "I will assist in the assessment and diagnosis of a client's mental health condition."
C
The nurse is assessing a 3-year-old child. Considering the child's stage of development, which approach by the nurse is most beneficial for the child during the assessment? A. Ask the parent to step out of the room during the exam to limit disruptions. B. Gently restrict the child's movement before, during, and after the assessment for accuracy. C. Offer the child a doll and equipment to play with before an assessment for cooperation. D. Use a stern and clear approach in communication to ensure cooperation.
C
The nurse is caring for a client in the mental health unit. The client describes a need for perfection and becomes anxious when the client's belongings are not aligned symmetrically. Which statement by the nurse will be included in the plan of care? A. "The symptoms of a cluster B type personality disorder will be monitored." B. "The main focus is on a diagnosis after a thorough assessment." C. "I am monitoring the client's coping skills and social interactions." D. "Observations for non-verbal data will be noted as I lead group therapy sessions."
C
The nurse is caring for a client who was active in a war and reports having "flashbacks and nightmares". The spouse is present and states the client does not sleep well, has become more irritable and is drinking alcohol more often. Which is the best approach for the nurse to interact with the client? A. Console the client by stating that things will get better with time. B. Ask the client to talk about the difficult experiences. C. Use nonjudgmental speech when talking about suicide. D. During a silent pause, keep talking to fill the quiet time.
C
The nurse is caring for several clients during a very busy shift. Which communication during this shift by the nurse is considered professional communication? A. A boisterous altercation with a UAP about not assessing vital signs promptly B. Responding to an agitated client with an aggressive confrontation C. Using the name of the client while communicating D. Using personal judgment to not disclose a diagnosis of Alzheimer disease to avoid distressing a client
C
The nurse is providing care for an adolescent client who had an episode of crying and hyperventilation and is accompanied by her parent. The parent states, "She was just overreacting because I made her attend the school dance." The client does not make any eye contact. Which is the best recommendation for the nurse to provide to the child? A. "Try attending more social events so that you get used to more people." B. "I suggest getting medication from your health care provider." C. "Let's all try some slow, deep breathing exercises together." D. "Try to talk this out with one of your best friends."
C
While interviewing a client admitted with poorly controlled schizophrenia, the nurse learns about the client's abuse of opiates. Which statement by the nurse to this client is most appropriate? A. "If you have pain, you could take something such as acetaminophen or ibuprofen." B. "You need to stop taking opiates; they are illegal and will make your condition worse." C. "Tell me more about why and when you are using opiates; we would like to help you." D. "Many people with your disorder have a substance abuse problem, so do not feel bad."
C
The parent of an adolescent client is concerned because their child wants to always spend time alone and has difficulty making friends. Based on the child's developmental stage, which is the best advice by the nurse? A. "Allow your child to establish independence, so that shame will not lead to low self-esteem." B. "Providing more responsive and sensitive attention to your child's needs will foster a secure trust between you." C. "Support your child without pressure while he struggles in finding and figuring out his identity and role." D. "Determine if difficultly in schoolwork or negative peer relationships are making your son feel inadequate."
C According to Erickson's theory of psychosocial developmental stages, adolescents ages 13-19 years of age are in the stage of identity versus role confusion. An adolescent is developing a sense of identity at this stage and relationships with peers are paramount to psychological and emotional well-being. Option A: Autonomy versus shame and doubt is a stage in Erikson's theory of psychosocial developmental stages describing early childhood (ages 1-3). At the stage of autonomy versus shame and doubt, the client is developing independence and control of their environment. A child should be allowed to make selections to foster independence, such as choosing clothes. Option B: Trust versus mistrust is the stage during infancy (age 1 month-1 year). The infant develops a sense of security and trust from the consistent parental care in meeting their needs. A child who has an unresponsive caregiver will exhibit feelings of mistrust and anxiety. Option D: Industry versus inferiority is the stage during school age (ages 6-12). Children will compare themselves to their peers in schoolwork, sports, or family and social life. If negative experiences occur, a feeling of inadequacy may develop.
A client on the psychiatric unit is in crisis and may be at risk of harming self or others. Which statement by a graduate nurse indicates understanding of how to respond to this situation? A. "When the client appears to be agitated, I should speak softly and slowly while backing out of the area to call for assistance." B. "I should tell the client to sit down with a firm, loud voice to take control of the situation." C. "I should assume an open posture, speak slowly, and choose words that indicate empathy for the emotions the client is experiencing." D. "I should call for help when the client is agitated to protect my safety and to help the client settle down or be placed in restraints if needed."
C Correct answer C: An open posture is less likely to be perceived as threatening by the client. Speaking more slowly decreases stimuli that can make a situation worse. Reflecting the client's emotions and expressing concern and empathy may help the client to realize that the nurse is listening and wants to help. Option A: Lowering the tone of voice and speaking more slowly can be helpful. However, the nurse has failed to realize that agitation is not the same as a crisis situation where the client threatens the safety of others or of themselves. A crisis may occur if the agitation is not decreased through other interventions. Option B: Attempting to take control of the situation by telling the client to sit down using a loud firm voice is apt to escalate the situation. This will likely increase the client's agitation and provoke an unsafe situation for the client or others. Option D: Agitation by the client does not always progress to a situation where the client or others may be harmed. Attempts to defuse the situation need to be taken quickly to prevent escalation. Restraints should be used minimally and only when a true risk of harm is evident. When restraints are needed, enough staff should be employed to keep the client and others safe and not left to one staff member to carry out this intervention.
The nurse is caring for a client in the mental health unit diagnosed with obsessive-compulsive disorder. Which statement, made by the client to the nurse, is associated with this disorder? A. "I really want to end it all." B. "I am so scared of meeting new people." C. "I must have two locks on my door." D. "I need my sheets changed weekly."
C Obsessive-compulsive personality disorder is characterized by the presence of obsessions and compulsions. Needing two locks on the inpatient facility door signifies an obsession for symmetry.
A client is living in a long-term assisted living facility after suffering a stroke with permanent hemi-paralysis. Which statement by the client reflects the highest level of Maslow's hierarchy of needs? A. "The nurses take care of all of my basic needs, such as bathing, medications, and treatments." B. "I believe I can make a full recovery here and then go home, where I belong and I am happier." C. "I know my movement is limited, but I love painting class because it makes me feel productive and happy." D. "My spouse comes to visit me every day, so I feel loved."
C The highest level of Maslow's hierarchy of needs is self-actualization that includes self-fulfillment needs. The client has accepted the limitations of their disease and has found self-fulfillment and joy by painting. This step represents a realization of the client's highest potential of an ideal self, or self-actualization, through acceptance, creativity, and fulfillment of potential. Option A: Basic needs, such as bathing, medications, and treatments, are part of the lowest level of Maslow's hierarchy of needs. This level involves the basic physiological needs of the client. Option B: This statement indicates that the client is in the mid-level of Maslow's hierarchy of needs representing the psychological needs of belongingness and love. This represents unrealistic expectations. These are expressions of a struggle at the lower level of the hierarchy, the level of psychological needs of belongingness and love, as opposed to finding fulfillment and self-actualization in the highest level of the hierarchy. Option D: Feeling loved is accomplished in the mid-level category of Maslow's hierarchy of needs. This level meets the psychological needs of the client for belongingness and love.
The nurse is caring for several clients in a long-term care facility. Which statements by the nurse are examples of therapeutic communication? Select all that apply. A. "I can't answer your questions now because I'm too busy; maybe I can talk to you tomorrow." B. "You'll have to change your lifestyle, or you will not live very long." C. "I understand that you are having difficulty with your insulin injections. We can work on it together." D. "How are you feeling today?" E. "I'm going to have to interrupt you so that we can discuss more important matters."
C, D
The nurse assesses an adolescent client who presents with breathing difficulty. The client states, "I feel like I'm drowning. My heart is pumping like crazy." Which nursing documentation indicates the client is experiencing anxiety? Select all that apply. A. "Client sits in a corner with the shoulders slumped and eyes closed." B. "Client does not respond immediately when asked a question." C. "Client is continually looking around the room while biting their fingernails." D. "Client states feeling 'shaky and sweaty'." E. "Client reports oversleeping each day."
C, D Correct answer C: A child who has anxiety may have a fear about a specific thing or situation, which manifests as physical symptoms. The nurse may notice that they keep looking around suspiciously, biting their nails, or appear restless, irritable, or tense. Correct answer D: Anxiety may make a child feel that their heart is pounding furiously and that they can't breathe. Some children may try to physically "shake off" the feeling by shaking their body to release anxious energy. The client may also complain of feeling sweaty or dizzy. Option A: A client experiencing anxiety would not be able to sit still in a corner. Oftentimes, when they are jittery, such clients cannot stop moving around or doing unnecessary gestures just to eliminate the feeling of anxiety. Option B: The lack of focus or inability to pay attention indicates depression. A child with anxiety can be extra sensitive to their environment and is attentive to the people around them because they feel that something bad is going to happen. They cannot seem to shake off the feeling of impending doom or fear about an unknown thing or situation. Option E: Oversleeping is often a symptom of depression, not anxiety. Anxiety may cause restlessness and lead to difficulty falling or staying asleep, restless sleep, or unsatisfying sleep.
The nurse is caring for an older adult client who is admitted after attempting suicide. During the initial interview with the client's family, the nurse gathers information about the client. Which factor most likely influenced this client's suicide attempt? A. Reading and napping more lately B. Being married for more than 50 years C. Having a large family with members living close to each other D. Recently retiring from a corporate job held for 45 years
D
The nurse is interviewing a client who reports insomnia and "feelings of hopelessness." During the interview, the client states, "I just don't want to do this anymore." Which question by the nurse is the priority to communicate to the client? A. "Tell me about your family support." B. "Do you use any recreational drugs or alcohol?" C. "Do you have employment and health insurance?" D. "Do you have a plan to kill yourself?"
D
The nurse is caring for a recently admitted client in the inpatient psychiatric unit. The client is an involuntary admission due to a recent suicide attempt and statements made of, "I will just try again and get it right the next time." The nurse approaches the client to give the prescribed oral fluoxetine. The client yells, "Get away from me, I am not taking your medications." Which is the best action for the nurse to take after this response? A. Inform the client that they cannot refuse medication because they are on an involuntary admission. B. Close the door to the client's room to decrease stimuli and educate the client regarding the medication. C. Prepare the medication as an intramuscular injection, summon sufficient staff to limit patient movement and inject the medication into the ventrogluteal area. D. Notify the attending psychiatrist that the client is agitated and is refusing the oral medication.
D (Clients on involuntary inpatient psychiatric admissions retain the right to refuse treatments and medications unless these are part of a court order.)
The nurse prepares to discharge a client who was newly prescribed alprazolam. Which instruction will the nurse provide to the client? A. "Stop taking this medication after a week so you don't develop a tolerance." B. "It is safe for you to drive when taking this medication." C. "Addiction is not a concern with this medication." D. "It is not safe to drink alcohol while taking this medication."
D Correct answer D: Alcohol and benzodiazepines are CNS depressants. It is not safe to drink alcohol or take opioid medications with benzodiazepines because it can increase the risk of CNS depression, sedation, and overdose, which can be fatal. The nurse will educate the client to not drink alcohol while taking alprazolam. Option A: The client will be weaned off benzodiazepines slowly, not stop them abruptly. It is also incorrect to state that a medication tolerance could result after a week. Although tolerance and physical dependence can occur with benzodiazepines, they are less likely to occur than with other CNS depressants. Option B: Common side effects of benzodiazepines include sedation, drowsiness, confusion, and short-term memory loss. Driving and taking a benzodiazepine could be very unsafe, especially if it is not yet known how the client will react to the medication. Option C: Benzodiazepines have a lower risk for abuse and dependence than barbiturates and opioids; however, there is still a potential for abuse. It is incorrect to tell the client that addiction is not a concern.
