Quizzes (Module8-11)
Nurse Rob has observed a co worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co worker? A Ignore the co worker's behavior, and frequently assess the clients assigned to the co worker. B Make general statements about safety issues at the next staff meeting. C Report the coworker's behavior to the appropriate supervisor. D Warn the co worker that this practice is unsafe.
c
Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to a. avoid shopping for large amounts of food b. control eating impulses c. identify anxiety causing situations d. eat only 3 meals per day
c
The ED nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? a. information regarding shelters b. instructions regarding calling the police c. instruction regarding self-defense classes d. explaining the importance of leaving the violent situation
a
The ED nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? a. adhering to the mandatory abuse-reporting laws b. notifying the caseworker of the family situation c. removing the client from any immediate danger d. obtaining treatment for the abusing family member
c
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-anon group if the nurse hears the wife make which statement? a. "I no longer feel that I deserve the beatings that my husband inflicts on me." b. "My attendance at the meetings has helped me to see that I provoke my husband's violence." c. "I enjoy attending the meetings because they get me out of the house & away from my husband." d. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."
a
The nursing diagnosis that would be most appropriate for a 22 year old client who uses ritualistic behavior would be a. ineffective coping b. impaired adjustment c. personal identity disturbance d. sensory/perceptual alterations
a
A client is unwilling to go to his church because his ex-girlfriend goes there & he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? a. avoidant b. borderline c. schizotypal d. obsessive-compulsive
a
A client with a diagnosis of borderline personality disorder has negative feelings toward the other clients on the unit & considers them all to be "bad". The nurse understands this defense is known as a. splitting b. ambivalence c. passive aggression d. reaction formation
a
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want anymore treatment. I have things that I have to do right away." The client has not been discharged & is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses & begins to walk out of the hospital room. What action should the nurse take? a. call the nursing supervisor b. call security to block all exits c. restrain the client until the health care provider can be reached d. tell the client that the client cannot return to this hospital again if the client leaves now
a
For a female client with anorexia nervosa, nurse Jimmy is aware that which goal takes the highest priority? a. the client will establish adequate daily nutritional intake b. the client will make a contract with the nurse that sets a target weight c. the client will identify self-perceptions about body size as unrealistic d. the client will verbalize the possible physiological consequences of self-starvation
a
For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? a. they tend to be overprotective of their children b. they usually have a history of substance abuse c. they maintain emotional distance from their children d. they alternate between loving & rejecting their children
a
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder & reflects anxiety management? a. engaging in immoral acts b. always reinforcing self-approval c. observing rigid rules & regulations d. having the need to always make the right decision
c
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. a. monitor vital signs b. provide a safe environment c. address hallucinations therapeutically d. provide stimulation in the environment e. provide reality orientation as appropriate f. maintain NPO status
a, b, c, e
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply a. dental decay b. moist, oily skin c. loss of tooth enamel d. electrolyte imbalances e. body weight well below ideal range
a, c, d
A client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. The client is due to return at 6pm. At 5pm the client telephones the nurse in charge of the unit & says "6 is too early. I feel like coming back at 7:30." The nurse would be most therapeutic by telling the client to a. return immediately, to demonstrate control b. return on time or restrictions will be imposed c. come back at 6:45, as a compromise to set limits d. come back as soon as possible or the police will be sent
b
A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tights & has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? a. normal behavior b. evidence of the client's disturbed body image c. regression as the client is moving toward the community d. indicative of the client's ambivalence about hospital discharge
b
Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using? A. Compensation B. Denial C. Suppression D. Undoing
b
Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? a. flexible role functioning between parents b. history of the parent having been abused as a child c. single parent home situation d. presence of parental mental illness
b
The home health nurse visits a client at home & determines that the client is dependent on drugs. During an assessment, which action should the nurse take to plan appropriate nursing care? a. ask the client why he started taking illegal drugs b. ask the client about the amount of drug use & its effect c. ask the client how long he thought that he could take drugs without someone finding out d. not ask any questions for feat that the client is in denial & will throw the nurse out of the home
b
The nurse in the ED is caring for a young female victim of sexual assault. The client's physical assessment is complete & physical evidence has been collected. The nurse notes that the client is withdrawn, confused, & at times physically immobile. How should the nurse interpret these behaviors? a. signs of depression b. reactions to a devastating event c. evidence that the client is a high suicide risk d. indicative of the need for hospital admission
b
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? a. increase socialization of the client with peers b. avoid using a whisper voice in front of the client c. begin to educate the client about social supports in the community d. have the client sign a release of information to appropriate parties for assessment purposes
b
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room & notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? a. interrupt the client & weigh her immediately b. interrupt the client & offer to taker her on a walk c. allow the client to complete her exercise program d. tell the client that she is not allowed to exercise rigorously
b
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? a. "why don't you tell your spouse about this?" b. "what do you find difficulty about this situation?" c. "this is not the best time to make that decision." d. "i agree with you. You should get out of this situation."
b
A client is admitted with a recent history of severe anxiety following a home invasion & robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? Select all that apply. a. "I'm afraid of spiders" b. "I keep reliving the robbery" c. "I see his face everywhere I go" d. "I don't want anything to eat now" e. "I might have died over a few dollars in my pocket" f. "I have to wash my hands over & over again many times"
b, c, e
A person with antisocial personality disorder has difficulty relating to others because of never having learned: a. count on others b. empathize with others c. be dependent on others d. communicate with other socially
b. with this disorder they are very aggressive. Often times it has to do with how they grew up
A client comes to the ED after an assault & is extremely agitated, trembling, & hyperventilating. What is the priority nursing action for this client? a. begin to teach relaxation techniques b. encourage the client to discuss the assault c. remain with the client until the anxiety decreases d. place the client in a quiet room alone to decrease stimulation
c
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"
c
During a home visit to a family of 3: a mother, father, and their child, the mother tells the community nurse that the father (who is not present) has hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to AA meetings & asks the nurse not to interfere, so her husband won't get angry & refuse treatment. Which of the following is the best response of the nurse? a. the nurse agrees not to interfere if the husband attends an AA meeting that evening b. the nurse commends the mother's efforts & agrees to let her handle things c. the nurse commends the mother's efforts & also contacts CPS d. the nurse confronts the mother's failure to protect the child
c
A young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week. He asks the nurse for her phone number so that he can call her for a date. The nurse's best response would be: a. "we are not permitted to date clients" b. "No, you are a client and I am a nurse" c. "I like you, but our relationship is professional." d. "it's against my professional ethics to date clients"
c. If you use any of the other options with their antisocial PD, they will get aggressive
A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the units rules. This behavior should be confronted because it will help the client: a. control anger b. reduce anxiety c. set realistic goals d. become more self-aware
d
During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? a. "I trust you not to purge" b. "How are you purging & when do you do it?" c. "Don't worry, I won't allow you to purge today" d. "I know its important for you to feel in control, but I'll monitor you for 90 minutes after you eat"
d
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? a. hypotension, ataxia, hunger b. stupor, lethargy, muscular rigidity c. hypotension, coarse hand tremors, lethargy d. hypertension, changes in LOC, hallucinations
d
