Which of the following responses by the nurse would be best

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Reference no: EM131108873

1. The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which of the following responses by the nurse would be best?
a. "The last few weeks?"
b. "You haven't had an appetite at all?"
c. "When the medication begins to work, you will begin to feel better."
d. "Think about everything that you have been through. It will take time for your appetite to improve."

2. A nurse in the emergency department is preparing to care for a female client who has just been sexually assaulted. Which of the following client behaviors would demonstrate denial?
a. The client is calm and quiet.
b. The client is blaming her sister for the incident.
c. The client is justifying unacceptable self-behaviors.
d. The client is verbalizing generalizations about the incident.

3. The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the physician immediately. The appropriate nursing intervention is which of the following?
a. Inform the client that the behavior is unacceptable.
b. Tell the client to wait in his or her room until report is over.
c. Offer to assist the client to an examination room until the physician is notified.
d. Tell the client that the physician will be called as soon as report is completed.

4. The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes that include the belief that the food is being poisoned. The nurse develops strategies that will encourage the client to discuss feelings and plans to:
a. Use open-ended questions and silence.
b. Focus on the components of adequate nutrition.
c. Focus on the fact that the client's beliefs are untrue.
d. Instruct the client about the need for adequate nutrition.

5. The mental health nurse has been meeting with a client on a weekly basis and, over the past several weeks, the client has been consistently 15 minutes late. Which of the following nursing actions is appropriate regarding the client's lateness for the scheduled meetings?
a. Ignore the behavior.
b. Tell the client that the meetings will be terminated.
c. Ask the client if something is going on that the client may have difficulty handling.
d. Because the client is consistently late, begin to arrive 15 minutes later than the scheduled time also.

6. A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn and interprets the client's behavior as:
a. An indication of the need for antidepressants
b. An inability of the client to terminate from the nurse
c. A normal behavior that can occur during termination
d. An indication of the need for additional therapy sessions

7. The nurse is preparing for the arrival of a new client at a drug abusers' residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is:
a. Milieu therapy
b. Aversion conditioning
c. Systematic desensitization
d. Cognitive-behavioral therapy

8. A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and instructs the client that:
a. The client will talk to himself or herself to control actions more effectively.
b. The client will take medication daily to control the condition.
c. The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.
d. The client will meet with others with the same problem in a support group that focuses on the client's phobia.

9. The nurse is conducting a group therapy session when a female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following?
a. Tell the client that it is not safe to leave.
b. Encourage the client to stay, and ask the client what she is feeling.
c. Tell the client that if she leaves she cannot return to this therapy group.
d. Lock the door so that the client cannot leave at this potentially vulnerable time.

10. The nurse is helping to conduct a group therapy session. During the session, a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action?
a. Tell the client that he must leave immediately.
b. Call security to come to the session immediately.
c. Tell the client that he can talk about his anger but cannot act on it in during the group session.
d. Tell the client that if he hits another client, he will be restrained and placed in seclusion.

11. The nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which of the following would be appropriate for the nurse to include in the plan of care?
a. Avoid providing rewards to the client.
b. Promote complete independence in the client.
c. Reward the client when a desired behavior is performed.
d. Provide consistent negative reinforcement to promote appropriate behaviors.

12. A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy?
a. "Milieu therapy provides a cognitive approach to changing behavior."
b. "A living, learning, or working environment is the focus of milieu therapy."
c. "Milieu therapy provides a behavior modification approach type of therapy."
d. "A behavioral approach to changing behavior is the focus of milieu therapy."

13. A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. When the nurse is alone with the client, however, the client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client?
a. "It is very, very hard to get over these types of feelings after being raped."
b. "What do you think you should do to reduce the likelihood that you will be raped again?"
c. "Tell me more about what happened, and what causes you to feel like the rape just occurred."
d. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

14. The nurse is developing a plan of care for a client admitted to the psychiatric unit at high risk for suicide. The focus of the plan is to promote a safe and therapeutic environment. Which of the following interventions would the nurse include in the plan of care?
a. Place the client in a private room.
b. Establish a therapeutic relationship.
c. Assign a leadership task to the client.
d. Maintain a distance of 10 inches at all times.

15. A client admitted to the mental health unit with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which of the following responses by the nurse would be therapeutic?
a. "You are certainly entitled to your own opinion."
b. "I know just how you feel. I have those days myself once in a while."
c. "I disagree with you; we all have some value and accomplishments in life."
d. "You seem very discouraged. Can you think of anything recently that went as you planned?"

16. A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?
a. Grandiose delusions of being a czar of Russia
b. Constant physical activity and poor oral intake
c. Constant, incessant talking, with sexual innuendoes
d. Outlandish behaviors and wearing odd and eccentric clothing

17. A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which of the following is the best response by the nurse?
a. "I don't believe that what you are telling me is true."
b. "There are no religious cults in this area that are going to kill you."
c. "What makes you think that cult members are being sent to hurt you?"
d. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

18. A woman is seen in the emergency department in a severe state of anxiety following assault and battery. The nurse places highest priority on taking which of the following nursing actions at this time?
a. Remaining with the client
b. Encouraging the client to talk about her feelings
c. Teaching the client deep-breathing techniques
d. Putting the client in a quiet room, away from other clients

19. An older female client with delirium becomes agitated and confused at night. The nurse's most important strategy for this is to do which of the following?
a. Turn off the television and radio, and use a nightlight.
b. Keep soft lighting and the television on during the night.
c. Change the client's room to one nearer the nurses' station.
d. Play soft instrumental music all night, and do not turn down the lights.

20. A mental health nurse is assigned to care for a client with a diagnosis of undifferentiated schizophrenia. The nurse uses which of the following approaches when planning care for this client?
a. Allow the client to set the goals for the plan of care.
b. Let the client act out initially, and use the quiet room and restraints as needed.
c. Provide assistance with grooming and nutrition until the client's thinking has cleared.
d. Repeatedly point out inconsistencies in the client's communication during initial treatment.

21. The nurse is talking with a male client who is actively hallucinating. The client is fearful that the voices he hears will direct him to kill himself or will hurt him directly. Which of the following nursing statements would be therapeutic at this time?
a. "I can hear the voices too, but they are telling you to go to bed now."
b. "I know whose voices you are hearing and told them not to hurt you."
c. "I know you believe they are going to cause you harm, but it's not true."
d. "I don't hear them, but it must be frightening to hear voices that others can't hear."

22. The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?
a. Ineffective coping
b. Chronic low self-esteem
c. Risk for self-mutilation
d. Social isolation

23. A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which of the following responses by the nurse would be therapeutic?
a. "I think you need to speak directly to the psychiatrist."
b. "Maybe you'll feel better if you see the ECT room and speak to the staff."
c. "Your mother has decided to have this treatment. You should support her."
d. "It sounds as though you are very concerned about the procedure. Let's discuss the procedure."

24. The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following?
a. Providing safety for the client and other clients on the unit
b. Offering the client a less stimulated area in which to calm down and gain control
c. Assisting in caring for the client in a controlled environment, such as a quiet room
d. Providing the other clients on the unit with a sense of comfort and safety by isolating the client

25. A female client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?
a. Ask direct questions to encourage talking.
b. Leave the client alone but check on her every 30 minutes.
c. Sit beside the client in silence, with occasional open-ended questions.
d. Take the client into the dayroom with other clients for added supervision.

26. A client who has sustained severe injuries in a motorcycle accident was diagnosed with intensive care unit (ICU) psychosis. The nurse would be most likely to conclude that the client's status is improving if the client:
a. Increases the number of hours slept at one time and is increasingly alert
b. Appears to be delirious but has stopped trying to pull out the nasogastric tube
c. Tells his wife, "I feel better, but the doctors want to give me a lethal injection."
d. Keeps his eyes fixed on the nurses while they are working in the room but has stable vital signs

27. A nurse caring for a client recently admitted to the hospital for anorexia nervosa enters the client's room and finds her in the middle of performing rapid exercises. Which action would be the priority?
a. Interrupt the client, and offer to take her for a walk.
b. Allow the client to complete her exercise program.
c. Ignore the behavior, and return when the client is finished.
d. Tell the client that she is not allowed to exercise rigorously.

28. The postsurgical client with a history of heavy alcohol intake is at risk for delirium tremens (DTs), which would be manifested by:
a. Hypotension, ataxia, muscular rigidity, and tactile hallucinations
b. Coarse hand tremor, agitation, hallucinations, and hypotension
c. Hypotension, stupor, agitation, headache, and auditory hallucinations
d. Fever, hypertension, changes in level of consciousness, and hallucinations

29. A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which of the following would be the therapeutic response by the nurse?
a. "This is not a good time to make that decision."
b. "What would your spouse think about your decision?"
c. "What aspects of this situation are the most difficult for you?"
d. "You seem to have a good grip on this situation. You probably should get out."

30. The nurse monitors this client with a history of opioid abuse for which of the following signs and symptoms associated with opioid withdrawal?
a. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
b. Increased appetite, irritability, anxiety, restlessness, anxiety, and altered concentration
c. Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), hypertension, agitation, and paranoia
d. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis

31. The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse suspects that the client has suddenly discontinued taking which of the following prescribed medications?
a. Sertraline (Zoloft)
b. Diazepam (Valium)
c. Haloperidol (Haldol)
d. Fluoxetine (Prozac)

32. A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which of the following roommate choices would indicate a lack of understanding by the nurse regarding the admitting client's health needs?
a. A client with pneumonia
b. A client who had back surgery
c. A client with a fractured pelvis
d. A client who has had a myocardial infarction

33. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which of the following actions at this time?
a. Call the nursing supervisor.
b. Restrain the client, and call the physician.
c. Call security to block the exits to the nursing unit.
d. Tell the client that readmission is not possible after leaving against medical advice (AMA).

34. The nurse will monitor the client with a history of heroin addiction for which of the following signs of heroin withdrawal?
a. Constipation, insomnia, and hallucinations
b. Staggering gait, slurred speech, and violent outbursts
c. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
d. Decreased heart rate and blood pressure and dry nose, mouth, and skin

35. The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if the client:
a. Exhibits impulsive behavior
b. Exhibits disorganized behavior
c. Has a history of suicide attempts
d. Has an immediate plan for a suicide attempt

36. A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which of the following comments by the nurse would be therapeutic at this time?
a. "What is causing you to become agitated?"
b. "Why are you intent on upsetting the other clients?"
c. "Please stop so I don't have to put you in seclusion."
d. "You are going to be restrained if you do not change your behavior."

37. A nurse is having a conversation with a depressed client on an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which of the following responses by the nurse would be appropriate at this time?
a. "You sound very unhappy. Are you thinking of harming yourself?"
b. "Those feelings will go away when your medication really takes effect."
c. "Have you talked to anyone specifically about what is bothering you?"
d. "I know what you mean; everyone gets that way when they are depressed."

38. The nurse interprets that which of the following comments by the client whose husband uses violence against her is consistent with the presence of low self-esteem commonly found with battered wife syndrome?
a. "I'm lucky to be married to a man who really loves me the way that he does."
b. "I told him that this is his last chance; if it happens again, I'm leaving for good."
c. "I stay because there's enough in it for me; I don't have to work full time this way."
d. "Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

39. The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which response to the client?
a. "That doesn't sound like the real you talking!"
b. "I'm sure you have someone if you think hard enough."
c. "It sounds as though you are feeling all alone right now."
d. "I don't believe that, and I really don't think you do either."


40. A client has been admitted to the inpatient psychiatric unit because the client has displayed violent behavior and is at risk for potentially harming others. Which of the following should the nurse avoid doing when caring for this client?
a. Admitting the client to a room near the nurses' station
b. Facing the client while speaking and providing nursing care
c. Arranging for a security officer to be available in the general area
d. Closing the door to the client's room when giving care to the client

41. A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing action at this time?
a. Stay with the client at all times.
b. Request that a friend of the client remain with the client at all times.
c. Have the client put on a hospital gown, and remove the client's clothing from the room.
d. Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed.

42. The client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today, the client appears in the dayroom dressed and well-groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?
a. Continue to monitor the client's behavior from a distance.
b. Document that the client is adapting to the unit and is feeling safe.
c. Notify the staff of these observations at the team meeting, which will begin in 3 hours.
d. Speak to the client personally about the nurse's observations, and ask if the client is thinking about suicide.

43. The nurse is preparing a client for discharge who was hospitalized following a suicide attempt. The nurse evaluates that the client could benefit from further development of coping strategies if the client was overheard making which of the following statements prior to discharge?
a. "I know now that I can't be all things to all people all the time."
b. "It is important for me to take my medications just as prescribed."
c. "It's been good to learn better ways to deal with the stresses in my life."
d. "I know that I won't become depressed again after the treatment I received here."

44. A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. The immediate nursing action is which of the following?
a. Take the client's vital signs.
b. Call the mental health crisis team and notify them that a client who attempted suicide is being admitted to the hospital.
c. Perform a focused assessment, paying particular attention to the client's neurological status.
d. Assess the client's respiratory status and for the presence of neck injuries.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

1. An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which of the following interventions would the nurse include? Select all that apply.
a. Assisting the client to identify and test negative cognition
b. Assisting the client to develop alternative thinking patterns
c. Assisting the client to participate in the treatment process
d. Assisting the client to rehearse new cognitive and behavioral responses
e. Assisting the client with the administration of antidepressant medications
f. Assisting the client's family to participate in group therapy on a regular basis

2. The nurse caring for the hospitalized client diagnosed with bulimia nervosa would closely monitor which of the following? Select all that apply.
a. Exercise patterns
b. Intake and output
c. Electrolyte levels
d. Pupillary response
e. Deep tendon reflexes
f. Elimination patterns

Reference no: EM131108873

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