Reference no: EM133881185
Questions
1. A client in a nursing home says to a nurse, "The giraffe has a long neck and leopard spots." Which response by the nurse would be appropriate?
'True, but go on. I'm not sure I fully understand you."
"You're right."
"Are you commenting on anyone here?"
'What does that have to do with us?"
2. In addition to calling for help, which of these actions should a nurse take first if a client is found hanging by the neck in an attempt at suicide?
Get scissors and cut down the client.
Notify the physician.
Observe the client for signs of life.
Lift the client's body.
3. Which statement by a child illustrates Erikson's stage of autonomy vs. shame and doubt?
'Don't let the teddy bear bite me."
'I'm going to wear this today."
"Help me."
"There's a monster in there."
4. A client who is admitted for alcohol detoxification says to a nurse, "I don't have an alcohol problem. I am only here because my wife thinks I am a drunk." Which interpretation and action made by the nurse are therapeutic?
The client is manipulative; set consistent limits with the client.
The client is rationalizing; focus on the actual results of the client's behavior.
The client is confused; provide reality-based responses.
The client is in denial; have the patient identify the effects of alcohol use on his life.
5. A nurse should observe a client who is considered to be suicidal for signs of increased risk. Which observation is a sign of increased risk?
Changes in activity level.
Willingness to talk with others.
Identification of support in the community.
Compliance with the treatment plan.
6. Which question should a nurse ask when assessing a client for evidence of alcoholism?
'What alcoholic beverages do you drink?"
"How much alcohol do you drink each week?"
"When did you first start drinking alcohol?"
"Where do you usually drink alcohol?"
7. A nurse has been notified that a client who has a diagnosis of acquired immunodeficiency syndrome (AIDS) is arriving from the emergency department. All of these actions will be taken. Which one should the nurse carry out first?
Identify your own feelings related to this diagnosis.
Greet the client by surname.
Show the client how to call the nurse.
Explain applicable policies.
8. Behavior modification is being used to teach a client in a nursing home to flush the toilet after using it. Which action by a nurse would be appropriate when the client demonstrates the target behavior?
• Administer the reinforcement immediately.
• Promise the client a special treat at bedtime.
• Have the client demonstrate the successful behavior to other residents on the unit.
Add handwashing to the task to be rewarded.
9. A client who is being discharged after in-client treatment is given instructions about taking lithium carbonate. Which statement by the client would indicate that the client understood the instructions?
I'll be coming to the laboratory to have my blood drawn."
" can stop this medication when I feel better."
"I'll avoid foods that contain tyramine.
I'm glad there's a cure for me."
10. A client who has a fluid-electrolyte imbalance states, "Look at all the snakes crawling across my bed." Which response by a nurse would be most appropriate?
"Describe the snakes you're seeing."
• "'lI catch the snakes and get rid of them."
• 'There are no snakes. I wouldn't be here if there were snakes here."
I ' don't see snakes. Your illness is causing you to see things that are not there"
11. An elderly client from a nursing home is admitted to the ambulatory surgery department for cataract surgery. While waiting on a stretcher, the client begins hollering and shaking the side rails. Which action should a nurse give priority to?
• Explain to the client that the client's behavior is upsetting others in the waiting area.
• Administer the client's prescribed sedative.
( Assess the client's orientation.
O Put a screen around the client's stretcher.
12. A client on the surgical unit says that "people" are out to get his savings each time a test or treatment is ordered. In addition to the surgical problem, the client has a diagnosis of paranoid schizophrenia. Which precaution should a nurse take when caring for this client?
• Offer evidence to disprove the suspicions.
Use explicit words to prevent misunderstandings.
© Ask the client to give his reasons for seeking help from people he distrusts.
• Agree that unnecessary tests are sometimes ordered.
13. A client expresses great distress over the "grotesque scars" (three pea-size pink discolorations on the abdomen) resulting from an endoscopic cholecystectomy. In order to respond effectively, a nurse should base intervention on the answer to which question?
© What makes some people overreact to everything?
• What if something really bad happened to this client?
What do these scars mean to this client?
• What does the client do for a living
14. Which client should an emergency room nurse assess first?
A 22-year-old client who ingested heroin and has severe bradypnea
A 32-year-old client who ingested cocaine and has hyperactivity.
A 42-year-old client who ingested marijuana and is very hungry.
A 52-year-old client who ingested alcohol and is ataxic.
15. A nurse approaches to assist a client out of bed for the first time after the client's abdominal surgery. The client says, "Stay away from me. You might drop me." Which action by the nurse should be used initially?
• Tell the client that the nurse has done this procedure many times.
Acknowledge that the client's fear is understandable.
Continue to carry out the procedure.
• Obtain assistance.
16. A resident in a nursing home slaps a nurse who is attempting to take the client to an activity. The client later apologizes to the nurse. Which response made by the nurse would probably be most likely to restore the nurse-client relationship?
© 'That's all right. You didn't really know what you were doing."
"Don't worry about it. It happens all the time."
"I hope you won't do it again. You should learn to control yourself."
"Thanks for apologizing. It was unpleasant to be slapped."
17. Seventy-two hours after a client's admission, a nurse observes that the client is having visual hallucinations, agitation, and restlessness and is perspiring. Which condition should the nurse suspect that the client is exhibiting?
• Mania.
• Hypertensive crisis.
Delirium tremens.
• Tardive dyskinesia.
18. The mother of two young children describes recent panic attacks to a nurse. The client says that family members have assumed shopping and child transport duties so that the client will have a reduction in panic attacks. Which interpretation made by the nurse is accurate?
The family's response decreases the client's need to manage the panic attacks.
The family's response indicates an understanding that the client has too many pressures.
Navigator
• The family's response indicates a recognition of previous inadequate support.
• The family's response increases the likelihood that the client's panic attacks will be cured.
19. A client on a medical unit taking psychotropic medication has extrapyramidal side effects. The client has all of these medication orders.
Which one should a nurse give for the side effects?
Furosemide.
Benztropine mesylate.
Navigator
Prochlorperazine.
Acetaminophen.
20. Which observation of a client who is receiving electroconvulsive therapy (ECT) indicates that the treatment is effective?
The client sleeps through the night.
• The client discusses previous mistakes.
• The client smiles often.
• The client bathes and grooms self.
21. A client who is to be discharged on lithium carbonate asks a nurse, "How can I best take this medication at home?" Which response should the nurse make?
"Reduce the amount of salt that you ingest each day."
"Take this medication on an empty stomach."
Navigator B
"Drink at least eight glasses of fluids daily."
"Avoid any foods that contain tyramine."