S3 Practice Written Comp #1 (3/2/23 ) - 56/70
25. A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber the nurse will mark to record the current drainage level.
Chest Tube - last row
54. A nurse is using the computer for documentation when a client calls for pain medication. What is the best action by the nurse? Ask another nurse to administer the pain medication. Ask the unlicensed assistive personnel (UAP) to inform the client that medication will be administered in about 15 minutes. Leave the computer terminal with entry open to complete documentation and administer the pain medication. Log out of the computer, then administer the pain medication.
Log out of the computer, then administer the pain medication.
20. A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first? Accept the client's behavior because it's probably culturally based. Observe how the client and the client's family and friends interact with one another and with other staff members. Read several articles about the client's culture. Ask staff members of a similar culture about the client's behavior.
Observe how the client and the client's family and friends interact with one another and with other staff members.
22. A client walks into the clinic and tells the nurse she wants to die because her boyfriend broke up with her. The client states, "I'll show him. He'll be sorry." The nurse notes which underlying theme and method to deal with the client? Escape—ask client to indicate what she wants to escape. Retaliation—ask client about her specific plans to harm herself and/or her boyfriend. Sadness—ask client to reveal how long she has felt this way. Loneliness—ask client to state who she believes to be her friends.
Retaliation—ask client about her specific plans to harm herself and/or her boyfriend.
58. Which scenario below complies with the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations? Two nurses in the cafeteria are discussing a client's condition. A nurse talks with the spouse about a client's condition. A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor. The healthcare team is discussing a client's care during a formal care conference.
The healthcare team is discussing a client's care during a formal care conference.
67. A nurse documents, "The client described the partner's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's: affect. blocking. feelings. mood.
affect.
2. The nurse who uses self-disclosure should: discuss the nurse's experience in detail. have the client examine what the nurse has revealed. refocus on the client's experience as quickly as possible. allow the client to ask questions about the nurse's experience.
allow the client to ask questions about the nurse's experience
1. While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client? standard precautions airborne precautions droplet precautions contact precautions
contact precautions
39. A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which factors for the client? feeling out of control and disgusted with self feelings of euphoria and gratification eating increasing amounts of food for substantial weight gain leaving traces of food around to attract attention
feelings of euphoria and gratification
9. A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication? lorazepam lithium carbonate thiothixene clozapine
lorazepam = Ativan
14. A client informs the nurse that the venipuncture site "hurts." The nurse should assess the site for which findings? Select all that apply. pain coolness redness firmness edema blanching
pain, redness, edema
56. After an upsetting divorce, a client who threatens to commit suicide with a handgun is involuntarily admitted to the psychiatric unit with major depression. What nursing action takes highest priority for the client? providing a safe environment consulting a spiritual leader promoting communication evaluating coping
providing a safe environment
32. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism? projection intellectualization regression reaction formation
regression
13. The nurse is assessing the skin of a client admitted with a stage II pressure ulcer. Which illustration represents a stage II pressure ulcer?
slight ulceration - not to SQ fat
36. A teenager was driving a car that slid off an icy road, killing two friends. The client repeatedly tells the nurse that the client should be dead instead of the friends. The client's behavior is an example of: survivor's guilt. repression. anticipatory grief. denial.
survivor's guilt.
15. A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called: looseness of association. flight of ideas. tangential thinking. circumstantial thinking.
tangential thinking
17. A client with acute stress disorder has avoided feelings of anger toward her rapist and cannot verbally express them. The nurse suggests which activity to assist the client with expressing her feelings? working on a puzzle writing in a journal meditating listening to music
writing in a journal
23. A family member accompanies a client to the clinic. The client's speech is disorganized but reports abdominal pain for several days. When the nurse attempts to assess the abdomen, the client pulls away and states "Do not touch me. I am sick from the poison the government puts in our water." The family member states the client has schizoaffective disorder. Which statement by the nurse shows effective communication with this client? "The government does not have time to poison our water, they are busy taking care of our country." "Your illness causes you to be rude and will not let you see the truth. You are not accountable." "Let me see if I understand, you have had pain in your stomach for a while now. Can you tell me more?" "I completely understand where you are coming from. You are sick and it is the government's fault."
"Let me see if I understand, you have had pain in your stomach for a while now. Can you tell me more?"
38. The husband of a client to be discharged from the hospital after an episode of major depression and a suicide attempt asks, "What can I do if she tries to kill herself again?" Which response is most appropriate? "Let's talk about some behavioral clues and resources that can help." "Tell her about your concern and just take care of her." "Don't worry. She'll be okay as long as she takes her medication." "She told me she wants to live, so I don't think she will try again."
"Let's talk about some behavioral clues and resources that can help."
40. A young client with a diagnosis of major depression and dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I don't know if I can make it in an apartment without my parents." How should the nurse respond to the client? "Your parents need a break, and you need a break from them." "Your parents will not be around forever. After all, they're getting older." "You're an adult now, not a child who needs to be cared for." "Your parents have been supportive and will continue to be even if you live apart."
"Your parents have been supportive and will continue to be even if you live apart."
11. A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of the spouse's alcoholism. The nurse should suggest that the family join which organization? Al-Anon Make Today Count Alcoholics Anonymous Emotions Anonymous
Al-Anon - for family of alcoholics
21. A registered nurse is overseeing the care of clients in an acute mental health setting. Which task can the nurse delegate to an unlicensed assistive personnel? Encouraging a client with depression to eat Teaching a client with schizophrenia about medications Initial assessment of a client admitted with bulimia Sterile dressing changes to a client's lacerated wrists
Encouraging a client with depression to eat
18. The nurse is assessing a client with a history of mental illness who has been brought to the emergency department by first responders. What characteristic of the client's status would most justify involuntary admission?term-56 The client has a history of nonadherence to treatment regimens. The clienThe client demonstrates a serious risk of self-harm.t demonstrates a serious risk of self-harm. The client has a longstanding history of major depression. The client lacks social support or a permanent residence.
The client demonstrates a serious risk of self-harm.t demonstrates a serious risk of self-harm.
51. A client is admitted to the emergency department after being found in a daze walking away from her burning car after an accident. She was not injured in the accident, but the other driver died. She states, "I can't handle it anymore. There's no point to it all." The crisis nurse recommends hospital admission based on the identification of which concern? The client is having delusions and is not in touch with reality. The client is expressing helplessness and hopelessness and is at risk for suicide. The client was walking around in a daze. The client has a lack of knowledge of what to do next.
The client was walking around in a daze.
46. An unemployed client, age 24, seeks help because of feelings of depression, abandonment, and lack of clarity about a life path. The client reports quitting the last five jobs because the coworkers didn't like the client. Last week, the client's partner broke up with the client after the client drove the partner's car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which behaviors by the client threaten the nurse-client relationship? suspiciousness, hypervigilance, and emotional coldness low self-esteem, strong dependency needs, and impulsiveness flat affect, social withdrawal, and unusual dress insensitivity to others, sexual acting out, and violence
insensitivity to others, sexual acting out, and violence
30. A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? letting the client eat with other clients to create a normal mealtime atmosphere providing one-on-one supervision during meals and for 1 hour afterward trying to persuade the client to eat and thus restore nutritional balance giving the client as much time to eat as desired
providing one-on-one supervision during meals and for 1 hour afterward
69. When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue? safety stress self-esteem sleep
safety
66. The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's: sound knowledge of psychiatric nursing. self-awareness and understanding. acceptance of others. sincere desire to help others.
self-awareness and understanding.
28. A hospitalized client is receiving treatment for severe depression. What is the best statement for the nurse to ask the client when assessing for suicidal ideation? "Will your family come in to visit?" "Would you like to stay alone in your room?" "Are you thinking of hurting yourself now?" "Do you have a plan to escape from here?"
"Are you thinking of hurting yourself now?"
55. 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? "Don't worry. I won't allow you to purge today." "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." "I trust you not to purge." "I need to know how and when you purge."
"I need to know how and when you purge."
45. During a conversation with the client, the nurse observes that the client is shaking his leg and tapping his fingers on the table next to him. Which statement by the nurse is best? "I know that you feel anxious. Let's discuss something more pleasant." "I'll get you something to help you feel less anxious." "I see that you're anxious. I'll be back later when you're calmer." "I noticed that your leg is shaking and you're tapping your fingers on the table. How are you feeling now?"
"I noticed that your leg is shaking and you're tapping your fingers on the table. How are you feeling now?"
16. It has been 5 months since a client lost his wife and child in a car-train accident. The nurse should determine that the client needs continuing counseling if he makes which statement? "I miss them so much, but I can tell I'm getting better day by day." "I wish I didn't have to sleep. I hate the nightmares about what the car looked like." "I'm sleeping, eating, and working pretty well, but I still get so sad at times." "I never thought I'd get over this, but I'm working with my legislator for train crossing safety."
"I wish I didn't have to sleep. I hate the nightmares about what the car looked like."
52. A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? "My son will be fine, but I may be charged with reckless driving." "If he dies, there will be nothing for me to do but join him." "I just did not see him run behind the car." "This accident will probably cost me my marriage."
"If he dies, there will be nothing for me to do but join him."
34. The client diagnosed with a fear of eating in public places or in front of other people has finished eating lunch in the dining area in the nurse's presence. Which statement by the nurse should reinforce the client's positive action? "It's progress for you to eat in the dining room with me." "You must have been hungry today." "It wasn't so hard, now was it?" "At supper, I hope to see you eat with a group of people."
"It's progress for you to eat in the dining room with me."
49. During morning community meeting, a client with bipolar disorder, manic phase, interrupts others to the point where no one can finish their statements. What should the nurse tell the client? "Please stop interrupting others. You can speak when it's your turn." "Please behave like an adult. Your behavior is childish." "If you can't control yourself, we'll have to take action." "Stop talking. It's time for you to leave the meeting."
"Please stop interrupting others. You can speak when it's your turn."
44. A nurse discusses an abused client and her family in a staff meeting. Which statement made by other staff members is likely to be most helpful to the nurse in developing a treatment plan? "This client sounds like a lot of women I know who don't want to change." "Call the client's mother to find out what she knows about the abuser." "Tell her to leave her husband immediately." "Suggest that she attend a group for battered women."
"Suggest that she attend a group for battered women."
31. After the client who attempted suicide regains consciousness, she says to the nurse, "I can't even kill myself. I can't even do that right." Which response by the nurse would be most therapeutic at this time? "Tell me more about how you're feeling." "You have a great deal to live for." "Why would you feel that way?" "I'm glad you survived."
"Tell me more about how you're feeling."
26. On admission to the mental health unit, a client tells the nurse about being afraid to leave the house for fear of criticism. The client informs the nurse, "My nose is so big. I know everyone is looking at me and making fun of me. I had plastic surgery, and it still looks awful!" What is the best response by the nurse? "Your nose looks perfect. Don't worry about it." "Have you felt your nose was big your entire life?" "Tell me more about your feelings regarding your nose." "I'm insecure about parts of my body too."
"Tell me more about your feelings regarding your nose."
27. Which nursing statement is most effective when the nurse is trying to defuse a client's impending violent behavior? "Do you feel you need to be alone in your room?" "Let's talk about what happened to make you this angry." "This is a good time for you to play cards with me." "The crisis team and I will escort you to the seclusion room."
"The crisis team and I will escort you to the seclusion room."
35. While helping clients brought to a crisis center during a severe flood, the nurse interviews a client whose pregnant wife is missing and whose home has been destroyed. The client keeps talking rapidly about his experience and says, "I can't see how I can ever rebuild my life." Which response by the nurse would be most appropriate? "If you start organizing your life now, I'm sure all will be fine." "Let me note a few of the things you said before you continue with your story." "This has been a terrible experience. Tell me more about how you feel." "Spend some time thinking about this so that we can continue this conversation tomorrow."
"This has been a terrible experience. Tell me more about how you feel."
12. A client suspected of being a victim of abuse returns to the emergency department and, sobbing, tells the nurse, "I guess you really know that my husband beats me and that's why I have bruises all over my body. I don't know what to do. I am afraid he'll kill me one of these times." Which response best demonstrates that the nurse recognizes the client's needs at this time? "We can begin by discussing various options open to you." "We can begin by listing ways to avoid making your husband angry with you." "You can legally leave your husband because he has no right to hurt you." "The fear that your husband will kill you is unfounded."
"We can begin by discussing various options open to you."
29. A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which statement by the nurse best deals with the client's feelings of "going crazy?" "Most people feel that way occasionally." "I haven't heard you make a crazy statement." "What do you mean when you say you think you're going crazy?" "I don't know you well enough to judge your mental state."
"What do you mean when you say you think you're going crazy?"
70. The nurse assesses a client who is pacing, is using profanity, and is argumentative. What is the best response by the nurse? "I do not understand why you do this? Can you explain what is wrong with you?" "This must be frustrating for you. Please take this medication to relax." "You seem to be upset. Can you tell me more about how you are feeling?" "I get upset sometimes too. Please come with me to your room so you can calm down."
"You seem to be upset. Can you tell me more about how you are feeling?"
10. A client diagnosed with depression states, "I'm looking forward to going back to work, but I wonder if I'll be able to keep up with the demands of my job." Which statement by the nurse would be most helpful? "You might need extra breaks at first until you feel better." "You'll do well. You have an excellent work record." "You sound concerned. I want to hear more about how you're feeling." "I wouldn't worry about it. The main thing to remember is that you can work."
"You sound concerned. I want to hear more about how you're feeling."
37. In talking with his nurse about discharge from a psychiatric hospital, the client says, "It's been easy not to get mad and hit people here because the staff won't let me. It's not the same at work." What would be the nurse's most effective response? "It's hard to leave the hospital, but you're better and need to get back to work. You'll be okay, I know." "We've helped, but you're the one who decided not to hit when you were angry. You can do that at work, too." "You sound worried about going back to work. The things you have learned here can help at work, too. Let's talk about what you learned and how you can use it." "Lots of people feel this way. You're just worried about leaving the hospital. You've learned so much that you won't have any problems at work."
"You sound worried about going back to work. The things you have learned here can help at work, too. Let's talk about what you learned and how you can use it."
68. A client is on isolation precautions for a hospital-acquired infection, and the client's visitors are not following the posted hand hygiene protocol. What is the nurse's best action? Report this to the healthcare provider to request an order restricting visitors. Explain to visitors the importance to the client of consistent hand hygiene. Document this for the insurance company to bill the client. Post "do not enter" and "report to the nurse's desk" signs on the hospital door.xplain to visitors the importance to the client of consistent hand hygiene. Document this for the insurance company to bill the client. Post "do not enter" and "report to the nurse's desk" signs on the hospital door.
Explain to visitors the importance to the client of consistent hand hygiene. Post "do not enter" and "report to the nurse's desk" signs on the hospital door.
50. A client with a diagnosis of anorexia nervosa is admitted to the psychiatric unit. The client is 5′ 8″ (1.7 m) tall, weighs only 103 lb (46.7 kg), and talks incessantly about how fat the client is. Which measure should the nurse take first when caring for this client? Explore the reasons why the client doesn't eat. Teach the client about nutrition, calories, and a balanced diet. Discuss cultural stereotypes regarding thinness and attractiveness. Establish a trusting relationship with the client.Establish a trusting relationship with the client.
Explore the reasons why the client doesn't eat.
57. The nurse is planning care with a client who is diagnosed with a depressive disorder. The client uses treatment by a root healer. Which intervention is most indicated? Explain that such beliefs are superstitious and should be forgotten. Involve the root healer in a consultation with the client, health care provider, and nurse. Explain to the client that Western medicine has a scientific, not mystical, basis. Avoid talking to the client about the root healer.
Involve the root healer in a consultation with the client, health care provider, and nurse.
65. A client who expressed suicidal ideations and was admitted to a psychiatric inpatient unit tells the nurse the next day that they feel fine, are at peace, and want to go home now against medical advice. What is the best recommendation for the nurse to make to the behavior health team? The client is possibly at more serious risk because the client may have gained sufficient energy to act on the suicidal ideation. The client requires further assessment. The client has resolved their feelings and is no longer at risk of self-harm. The client has had sufficient time to consider their situation and has a realistic appraisal of the serious nature of the suicidal ideations. The client is ready to be discharged home because the client's suicidal intent has been resolved.
The client is possibly at more serious risk because the client may have gained sufficient energy to act on the suicidal ideation. The client requires further assessment.
33. The nurse reviews laboratory work for a client who is admitted to the acute psychiatric unit for an eating disorder (see figure). Which finding does the nurse report to the health care provider? Select all that apply. hematocrit level albumin level sodium level potassium level hemoglobin level
hematocrit level albumin level potassium level hemoglobin level
47. Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is: generativity versus stagnation. trust versus mistrust. intimacy versus isolation. industry versus inferiority.
intimacy versus isolation.
48. A client with major depression is to be discharged home tomorrow. When preparing the client's discharge plan, which area is most important for the nurse to review with the client? medication management with outpatient follow-up future plans for going back to work a conflict encountered with another client results of psychological testing
medication management with outpatient follow-up
53. A client is voluntarily admitted to a substance use disorder unit. The client admits to drinking at least 1 qt (1 L) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings will the nurse document as evidence of alcohol withdrawal? pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness vomiting, watery frequent diarrhea, and pulse below 80 beats/minute blood pressure of 90/50 mmHg, decreased appetite, and somnolence dehydration, temperature above 101°F (38.3°C), and pruritus
vomiting, watery frequent diarrhea, and pulse below 80 beats/minute
