Reference no: EM133522208

Question

1. A client is disorganized, delusional, and loosely associated. Which goal should a nurse work towards first?

The client will interact with the nurse.

The client will speak logically.

The client will recognize that delusions are false.

The client will connect with peers.

2. Which goal should a nurse recognize as the highest priority for a client who has anorexia nervosa?

The client's fluid and electrolyte status is stable.

The client's body weight is within the ideal range.

The client identifies healthy diet recommendations for age.

The client acknowledges having an eating disorder.

3. A client who has been taking anti-psychotic medication for several days develops a fever, tremors, urine incontinence, and muscle rigidity.

Which action should a nurse take first?

Assess the client for extrapyramidal side effects of the medication.

Sit calmly with the client to reduce the client's trembling.

Hold the next dose of the antipsychotic medication.

Increase the client's oral fluid intake.

4. Nurses on the surgical unit receive clients who recently arrived from the post-anesthesia recovery room. Which understanding of instructions regarding the use of the client-controlled analgesia (CA) system should a nurse expect of those clients?

They will be so fearful of pain that they will be especially attentive at this time.

Having been taught preoperatively, they will not need further instruction at this time.

They will be alert and responsive to the information given at this time.

Their understanding of instructions should be assessed periodically.

5. A client says of her boyfriend who had died while jogging, "He'd be alive today if I hadn't talked him into running." Which response made by the nurse reflects the client's feelings?

"He didn't have to follow your recommendation.

'You couldn't know that would happen

"You blame yourself."

"He died while running.

6. A man says to a nurse, "I beat my wife because she does not listen to me." The nurse should recognize this statement as an example of which defense mechanism?

Denial.

Sublimation.

Displacement.

Rationalization.

7. A client who was admitted to a nursing home two weeks ago blames the client's daughter for not wanting to care for the client at home. Which approach, made by a nurse, is appropriate?

Explain to the nurse that the daughter wants the client to be safe.

Encourage the client to describe the negative feelings.

Suggest that the client ask the social worker to arrange new housing.

Change the topic so the client does not dwell on negative feelings.

8. A nurse plans to monitor a client who is receiving risperidone for manifestations of the extrapyramidal side effect of akathisia. Which side effect should the nurse plan to monitor for?

Drowsiness.

Restlessness.

Dry mouth.

Dizziness.

9. A client says to a nurse, "Get down. They can see you. I will never get out of here alive." Which response made by the nurse is therapeutic?

'We are all safe. We are in a hospital."

"You sound frightened."

"Are you worried about going home?"

"Exactly; who are you talking about?"

10. A client is having chemotherapy following surgery to remove cancer of the uterus. The client says to a visiting nurse, "It's no use. Things will never get better." Which response by the nurse would be therapeutic?

"You seem discouraged about your treatment."

"Things will get better. It takes time."

"You're not helping yourself by being so negative."

'The treatment is tough, but people do recover."

11. A hospitalized client who is having hemodialysis is thought to be suicidal. A nurse plans to instruct the client about suicide precautions.

Which comment by the nurse would be indicated?

'These measures are employed for those who are receiving hemodialysis in the hospital."

"We are concerned that you have thoughts of harming yourself."

'The nurses provide this treatment for all of the clients."

'We're just following orders that were given by the nurse manager.

12. The daughter of an elderly woman who has dementia reports that her mother has difficulty managing hygiene activities in the home.

Which suggestion should a nurse give to the daughter?

'Vary the daily routine. It is likely that your mother is easily bored."

"Offer your mother more choices as to when she would like to bathe."

"Break down each task into small steps for your mother."

"Leave your mother alone; eventually, she will decide to bathe."

13. A nurse slams a client's chart down on the desktop following a reprimand by the supervisor. Which of these defense mechanisms does this demonstrate?

Rationalization.

Undoing.

Displacement.

Compensation.

14. Which manifestation should a nurse expect to identify in a client who has depression?

Powerlessness and anorexia

Pressured speech and irritability.

Irrational fears and diarrhea.

Perceptual disturbances and weight gain.

15. A client receives lorazepam at 7:00 PM for a panic attack. The nurse observes the client two hours later. Which observation indicates that the medication is having the desired effect?

The client describes previous anxiety triggers at length.

The client sits in bed reading a magazine.

The client smiles while walking around the unit.

The client looks calmer during the scheduled evening activity.

16. Which goal is the priority for a client who is to be discharged after alcohol detoxification?

The client agrees to stop drinking after discharge.

The client identifies situations associated with alcohol use.

The client plans to join a peer support group.

The client speaks about family issues related to alcohol abuse.