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139 Cards in this Set

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A client says to the nurse, "I feel close to you. You are the only true friend I have." The most therapeutic response the nurse can make is:
"Since ours is a professional relationship, let's explore other opportunities in your life for friendship."
A client in a substance abuse treatment program asks the nurse for a date after the client is discharged. A nurse talks to a client about the importance of a therapeutic relationship and its characteristics. The nurse is using which of the following techniques?
Defining boundaries
The nurse is explaining the therapeutic nurse-client relationship to a new client. The focus of this relationship is on a client's:
Needs as he or she perceives them
One of the primary differences between social and therapeutic relationships is the:
Type of responsibility involved
Suppression of information, intellectualizing, and superficial conversation are examples of:
Resistance
A nurse is assigned to care for a client whose sexual orientation differs from her own. She would need to seek clinical supervision if she attempted to:
Assist the client to change values
The nurse initiating the therapeutic relationship with a client should explain the purpose, which is to:
Establish relationships to facilitate a positive change
Which is the following is an essential component that a nurse must bring into a therapeutic nurse-client relationship?
Empathy
To promote the client's self-awareness, the nurse must possess:
Self-awareness
In what phase of the therapeutic nurse-client relationship is transference most likely to occur?
Working
The client tells the nurse, "I don't think you can help me. Every time I talk to you, I am reminded of my mother, and I hate her." The nurse should recognize this as:
Transference
Which of the following statements is true about a nurse's self-disclosure?
Nurse self disclosure should not be done, unless it has identified therapeutic outcomes.
The primary goal of a therapeutic nurse-client relationship is:
Promoting the client's growth
During a regular home health visit to an elderly client, the nurse observes that a client has feelings of hopelessness and despair. The client says, "I'm old, and my life has no purpose anymore. But promise me you won't tell anyone." How should the nurse respond?
"I'm sorry, but I can't keep that kind of secret."
During the working phase of a therapeutic relationship, which of the following actions by the nurse would best help a client to explore problems?
Encouraging the client to clarity feelings and behavior
Which action by a psychiatric nurse supports the client's right to be treated with dignity and respect?
The nurse addresses the client using his title and surname, Mr. Jones.
What is the legal significance of the nurse's action when a client verbally refuses his medication and the nurse gives it over his objection?
The nurse can be charged with battery.
Which intervention is an example of a breach of a client's constitutional right to privacy?
The nurse releases information to the client's employer regarding his condition without the client's consent.
When a client criticizes the care received on the 11-7 shift, the nurse replies, "How can you complain about the night nurse? She is a fine person and tries as hard as she can." This is an example of a non-therapeutic technique called:
Defending
The following interaction is an example of which therapeutic communication technique? Client: "I had an accident." Nurse: "Tell me about your accident."
General lead
The nurse is admitting a new client and focusing on risk factors that could affect the health of this client. What phase of the nursing process is the nurse performing?
Analysis
Identify the rationale for documenting and planning a patient's care.
It provides continuity of care
Which of the following nursing diagnoses would be applicable to a patient who has rheumatoid arthritis?
Self-care deficit related to fatigue and joint stiffness
A nurse is caring for a client with a fractured hip. The client is combative and confused, and he is trying to get out of bed. The nurse should:
Obtain a physician's order to restrain the client
The physician has prescribed restraints for a client. The nurse knows that it's inappropriate to apply restraints on a client when:
The unit is short-staffed, and the nurse restrains for staffing convenience
How might the nurse establish a good rapport with the patient during the initial assessment interview?
Ask open ended questions
A client is being discharged from an acute care facility following treatment for right let thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
Evaluation
One hour after the administration of phenergan to a patient with nausea and vomiting, a nurse determines that the medication has been effective and documents this in the patient's record. This phase of the nursing process is termed:
Evaluation
When the nurse administers an antiemetic medication to a patient who is suffering from postoperative vomiting, the phase of the nursing process accomplished by the nurse is the:
Implementation phase
Which of the following would be classified as the planning phase of the nursing process for the patient diagnosed with pneumonia?
Improved airway patency
Your patient is admitted with pneumonia. He is receiving IV antibiotic therapy. He is lethargic, intolerant of exertion, and his saturations are 88%. What is his actual nursing problem?
Low saturations
What is the above patient's potential nursing problem?
Skin integrity, breakdown
You prepare to chart on your patient using the computer system. You check the patient's name, account number, and medical record number. You also check the doctor's name, before beginning your documentation. This is an example of what type of error prevention?
Human factors engineering
A beginning nurse would approach problem solving in what manner?
Scientific problem solving
An experienced nurse will approach problem solving in what manner?
Intuition
You answer your patient's call light, he complains of a sense of "shocks" on the EKG leads, while the technologist is doing a bedside cardiac test. You explore this and find water puddled around and under his bed. You call maintenance, move the patient to another room (once checked for safety), and verify the patient is comfortable. This is an example of what type of error prevention?
Environment
Your patient has been in the news as being a suspect in a brutal crime. While caring for this patient, what must you do to follow the process of critical thinking skills?
Remove judgment
Your patient is diagnosed with exercise-induced asthma. He stated that this is just an infliction. For you, it would be devastating. How would you apply this to the critical thinking process?
Recognition of different views/feelings of nurse and patient
Your patient is a known cardiac patient admitted for another diagnosis. When reviewing the orders, you see lasix and digitalis ordered, medications taken at home. When reviewing the patient's dietary selections and the orders, you notice that a potassium supplement needs to be considered. This is an example of what type of error prevention?
Verify accuracy of orders
Taking care of one diabetic, learning about the care involved, and applying that knowledge to the next diabetic patient is an example of what step in the process of critical thinking?
Form inferences
What is the difference between nursing diagnoses and the DSM-IV-TR?
Nursing diagnoses are used for actual and potential patient problems.
Your patient is admitted and demonstrates that he has altered thought processes, delusions, and experiences obsessions. Where do you document this information in the psychosocial assessment?
Mental status exam
Cognitive therapy is considered effective for what disorder?
Depression
Your patient is admitted with the following nursing diagnoses: alteration in skin integrity (self-inflicted wounds); alteration in body weight, less than expected (poor food intake); and knowledge deficit, understanding admission, and disorder. What would be the priority for planning interventions?
Patient safety, food intake, patient teaching
Your co-worker is over heard stating, "I don't understand people from Brontoesia, they have such funny food and they refuse to learn how to live in the U.S." This co-worker is expressing:
Prejudice
Techniques of data collection for the patient assessment include all of the following except which of the following?
Calling past care facilities for their opinions on the patient.
A patient assessment includes recent medical evaluations, past hospitalizations, childhood illnesses, history of cardiac problems, respiratory problems, and neurologic problems to name a few, where in the assessment would these be documented?
Current and Past Health History
You plan to perform interventions so that your patient can perform their own ADL's, gain motivation and initiative, and work to improve the patient's ability to sleep through the night. These interventions are part of what domain?
Biologic
Your patient has had difficulty following the designated rules on the floor. You decide to reward the patient when he follows the rules and not to reward the uncooperative behavior. What type of behavior therapy would this be an example of?
Behavior modification
Milieu therapy is best applied to those patients with what mental disorder?
Developmental disabilities
Dialectical behavior therapy is effective with which mental disorder?
Borderline personality disorder
An outcome for your patient is that she will demonstrate health behavior. Which behavior indicates the outcome is being met?
She sees herself as approaching her ideals, and as capable of meeting demands.
The complete assessment includes perceptions of the client. What is assessed with in this assessment category?
Presence of hallucinations
The nurse receives three telephone calls regarding a newly admitted client. The psychiatrist wishes to see the client for an assessment interview, the medical doctor wants to perform a physical examination, and the client's lawyer wishes to set up an appointment to see him. The nurse schedules the three activities for the client. This exemplifies the role of the nurse referred to as:
Coordinator of care
Which document pertaining to client care would a student beginning clinical experience on a psychiatric inpatient unit be justified in reading last?
Unit Seclusion and Restraint Policies
A client is observed to have a high level of non-goal-directed motor activity, running from chair to chair in the solarium. He is wide-eyed and seems terror stricken. He cries, "They're coming! They're coming!" He neither follows staff direction nor responds to verbal efforts to calm him. The initial nursing intervention of highest priority is:
Provide for client safety
When the nurse asks the client to describe her social supports, the client gives the following information: she is divorced; has no siblings; her parents died last year; and she has contact with her ex-in-laws who subtly blame her for the divorce. With regard to the relationship with her in-laws, the nurse can prioritize the care plan to include:
Low quality support relationships often negatively affect coping in a crisis
The mental status portion of the assessment includes all of the following except:
Spiritual beliefs
Which of the following question is best to ask when assessing the client's judgment?
"If you found yourself downtown without money for a car, how would you get home?"
A delusion represents a problem in which of the following areas?
thinking
Disorders that involve a disruption of comprehension, judgments, memory, and attentiveness are:
cognitive disorders
Your patient is brought in by her family members and they seem very tired and anxious. The patient's daughter tells you, "Mom started forgetting things, that seemed ok, but then she just couldn't do things like she used to. I am so scared; I remember my grandmother was like this." Which of the following could she be describing?
Dementia
M., your patient, was brought in with his friends from school. M. is alert and talking effectively. He seems preoccupied with leaving and wanting to go with his friends. One of his friends says that he just "woke" as they were driving here. M. had 12 beers and a few shots and seemed to have passed out. His friends became concerned when they realized that M. has been drinking more and more drinks at a time. This behavior describes which concept of addiction?
tolerance
Your patient discussed, in group, that being with her family was always unhappy for her. She describes her family as not very close, not a source of support, and her parents did not instill any solid values. This describes what theory of addiction?
Psychological
Susie was admitted for severe weight loss. Her parents state, "she just doesn't eat." Despite their efforts, Susie refuses to eat. In session, Susie describes her parents as overprotective because they refuse to allow her to go out after dark and they do not let her take part in school activities for fear she will use drugs or get pregnant. Which of the following etiologic factors may have contributed to Susie's eating disorder?
Developmental
Katie was admitted with a diagnosis of bulimia. What is one intervention that the nurse can implement for this patient?
Accompany her after meals, taking a walk, or talking
John was described by his family as "different" from the other kids. He was brought in because he missed a free throw and threw the basketball across the court and into the first row of chairs, yelling that the basketball was dumb. Fearing he might hurt someone or himself, his parents were called and they brought him in. What disorder describes this behavior?
Personality
Your patient saw the movie Harry Potter and began to slowly dress like Harry in the movie. He carried a wand and attempted to use magic on those who angered him. He was suspicious that the bad wizard was trying to kill him. He created a new language so no one would understand him. Which of the following personality disorders describes this behavior?
Schizotypal personality disorder
J. was just brought in for care, after being pulled over for suspicion of drunken driving. You do an initial assessment and explain for the first 48 hours, he cannot have a pass to leave the facility. This is a standard rule. Within an hour, the pastor comes out of his room and says that J. wants to attend church on (today is Saturday) Sunday and was in need of a pass to attend. The behavior isn't unusual for which of the following personality disorders?
Antisocial personality disorder
A college student is observed poking herself with a needle, talking about suicide, and says she is just so bored and empty. She is going to drop out of school because no one is willing to help her; she says no one cares about her. She fears that her roommate may decide to move off campus. What personality disorder might be described in this case?
Borderline personality disorder
The problem that is most likely to occur when a nurse sets unrealistically high goals for an antisocial client is:
The nurse becomes frustrated and angry with the client when goals are not met.
A., a client with paranoid personality disorder, is noted sitting alone in a corner of the unit living room. When another client tries to interact, A. is haughty or simply ignores the other client. When staff invites her to join an activity, she tells them, "I have little tolerance for that sort of thing." A nursing diagnosis that should be considered is:
impaired social interaction
M., a client with borderline personality disorder, has come back from a pass, having lacerated her wrists. For future planning, it is important for staff to consider the reason for the self-mutilation. M.'s self-mutilation may be explained as:
Related to fear of abandonment brought on by movement toward autonomy and independence (earning a pass)
A priority nursing intervention undertaken by the nurse dealing with clients with personality disorders is:
Communicating positive expectations
Your patient is admitted with a history of severe mental illness. In coordinating this patients' care, which of the following must be taken into account?
All of the above
All of the following nursing interventions are appropriate for the severely mentally ill, except?
Support for medication adherence
What issues contribute to the state of homelessness of the mentally ill?
The homeless mentally ill tend to not stay in available housing
Your patient has been diagnosed with terminal cancer. She sits in the bed and cries, refuses to eat, isn't sleeping well, and has withdrawn from family. What complication has been added to the cancer diagnosis?
Depression
Your elderly patient has been restless, agitated, and has had elevated HR. These problems indicate that:
The patients' pain may not be sufficiently managed
Disorders that involve a disruption of comprehension, judgments, memory, and attentiveness are:
cognitive disorders
Your patient is brought in by her family members and they seem very tired and anxious. The patient's daughter tells you, "Mom started forgetting things, that seemed ok, but then she just couldn't do things like she used to. I am so scared; I remember my grandmother was like this." Which of the following could she be describing?
dementia
M., your patient, was brought in with his friends from school. M. is alert and talking effectively. He seems preoccupied with leaving and wanting to go with his friends. One of his friends says that he just "woke" as they were driving here. M. had 12 beers and a few shots and seemed to have passed out. His friends became concerned when they realized that M. has been drinking more and more drinks at a time. This behavior describes which concept of addiction?
tolerance
Your patient discussed, in group, that being with her family was always unhappy for her. She describes her family as not very close, not a source of support, and her parents did not instill any solid values. This describes what theory of addiction?
psychological
Susie was admitted for severe weight loss. Her parents state, "she just doesn't eat." Despite their efforts, Susie refuses to eat. In session, Susie describes her parents as overprotective because they refuse to allow her to go out after dark and they do not let her take part in school activities for fear she will use drugs or get pregnant. Which of the following etiologic factors may have contributed to Susie's eating disorder?
developmental
Katie was admitted with a diagnosis of bulimia. What is one intervention that the nurse can implement for this patient?
Accompany her after meals, taking a walk, or talking
John was described by his family as "different" from the other kids. He was brought in because he missed a free throw and threw the basketball across the court and into the first row of chairs, yelling that the basketball was dumb. Fearing he might hurt someone or himself, his parents were called and they brought him in. What disorder describes this behavior?
personality
Your patient saw the movie Harry Potter and began to slowly dress like Harry in the movie. He carried a wand and attempted to use magic on those who angered him. He was suspicious that the bad wizard was trying to kill him. He created a new language so no one would understand him. Which of the following personality disorders describes this behavior?
Schizotypal personality disorder
J. was just brought in for care, after being pulled over for suspicion of drunken driving. You do an initial assessment and explain for the first 48 hours, he cannot have a pass to leave the facility. This is a standard rule. Within an hour, the pastor comes out of his room and says that J. wants to attend church on (today is Saturday) Sunday and was in need of a pass to attend. The behavior isn't unusual for which of the following personality disorders?
antisocial personality disorder
A college student is observed poking herself with a needle, talking about suicide, and says she is just so bored and empty. She is going to drop out of school because no one is willing to help her; she says no one cares about her. She fears that her roommate may decide to move off campus. What personality disorder might be described in this case?
borderline personality disorder
The problem that is most likely to occur when a nurse sets unrealistically high goals for an antisocial client is:
The nurse becomes frustrated and angry with the client when goals are not met.
A., a client with paranoid personality disorder, is noted sitting alone in a corner of the unit living room. When another client tries to interact, A. is haughty or simply ignores the other client. When staff invites her to join an activity, she tells them, "I have little tolerance for that sort of thing." A nursing diagnosis that should be considered is:
Impaired social interaction
M., a client with borderline personality disorder, has come back from a pass, having lacerated her wrists. For future planning, it is important for staff to consider the reason for the self-mutilation. M.'s self-mutilation may be explained as:
Related to fear of abandonment brought on by movement toward autonomy and independence (earning a pass)
A priority nursing intervention undertaken by the nurse dealing with clients with personality disorders is:
Communicating positive expectations
Which assessment would a nurse be most likely to make when working with a client with a personality disorder:
Client behavior is inflexibly dysfunctional
Your patient is admitted with a history of severe mental illness. In coordinating this patients' care, which of the following must be taken into account?
All of the above
All of the following nursing interventions are appropriate for the severely mentally ill, except?
Support for medication adherence
What issues contribute to the state of homelessness of the mentally ill?
The homeless mentally ill tend to not stay in available housing
Your patient has been diagnosed with terminal cancer. She sits in the bed and cries, refuses to eat, isn't sleeping well, and has withdrawn from family. What complication has been added to the cancer diagnosis?
depression
Your elderly patient has been restless, agitated, and has had elevated HR. These problems indicate that:
The patients' pain may not be sufficiently managed
Your patient is admitted with severe agoraphobia. A nursing intervention for this patient would be:
Clearly identify the exits and doorways to the patient
A female patient is in the recreation room and a male patient then comes in. The first patient begins screaming and yelling, "No, no, not again!" This behavior would be consistent for a patient with what anxiety disorder?
ptsd
Your patient is complaining of a headache, she is laying in her bed crying, "I have a brain tumor, I just know it, I am dying, I have to say good-bye to my family." This is consistent with which of the following disorders?
hypochodriasis
A mother continues to bring her little girl in the ER stating that she is having trouble breathing. When admitted, the mother is surrounded by family and friends. Without a clear diagnosis to explain the difficulty breathing with the little girl, she could be the victim of:
munchausen syndrome by proxy
Your patient was found after years of searching. He had taken on a new identity, married another woman, and had a child. His family had been looking for him after he failed to come home after work a few years ago. This person may have what disorder?
fugue
Your patient, when interviewed, has no recollection of the year 2001. When you investigated this, you found that his wife died that year. Your patient may be experiencing:
Amnesia dissociative disorder
Male rapists tend to have the following characteristics, except:
Desire for someone to take control
Your patient came in the ER with bruises and rib fractures. When interviewing the patient, you find that she lacks a support system, is unable to make a decision, and declares herself as unworthy of your attention. This woman may be experiencing:
Victim of family violence
Your elderly patient is ready for discharge. She is going to a retirement village and seems excited. Her daughter arrives and is angry that her mother isn't going home. She raises her voice to her mother about this decision and calls her ridiculous for going elsewhere. The daughter states that her mother is going home and that is final. Your patient shrugs and says, "I better do what she says." Your patient may be experiencing:
elder abuse
J., age 4, who was removed from preschool when the teacher was unable to handle his excessive motor activity and talking, is to be treated by a psychiatric clinical nurse specialist. What aspect of J.'s care can be performed by a clinical nurse specialist, but would not be performed by a nurse generalist?
Participating in child psychotherapy
Shortly after her parents announced that they were divorcing, M., a 15 year-old high school junior, stopped being a cheerleader, began to sit alone at lunch and began to avoid former friends. At home, she spends most of her time in her room. M. tells the nurse, "All the kids at school have families. Now that my parents are divorcing, I'm an outsider. If my parents loved me, they would work out their problems." What nursing diagnosis should be considered based on the assembled data?
Social isolation
F., age 15, has been referred to the adolescent mental health clinic by the juvenile court after being arrested for prostitution. She has run away from home several times and has lived in homeless shelters. Her parents told the court they could not manage her, that she was physically abusive to her mother, defiant, and hostile to her father. From F.'s history, the nurse might anticipate that the psychiatrist will consider the diagnosis of _____.
Conduct disorder
When C., age 11, is disruptive, the nurse tells her, "C., you must take a time-out." What is expected of C.? She will ___________.
Sit on the periphery of the activity until regaining self-control and reviewing the episode
Your patient was brought in because he seemed to be not reaching his developmental milestones. Your observations revealed a 2-year-old, male, uncoordinated crawl, poor balance for walking, non-verbal but grunts, was told by his mother to say hello to you. A diagnosis that you may prepare for once his is evaluated by the physician is:
mental retardation
Your patient, K., was brought in for evaluation. His mother describes K. as being quite precocious when he was a baby, seemed very social, started talking early, and they thought he would be gifted. Then, at three, he started to isolate himself, stopped communicating, and wouldn't interact. What diagnosis would you prepare for?
autistic disorder
You are caring for a 14 year-old, female, J. She is in for out pt surgery and will go home with her mother. Her mother walks her to the OR door and says good-bye. J. begins crying and screaming, kicking, and refusing to cooperate. One nurse determines that J. is fearful of surgery and tries to calm J. Listening to J. screaming, she is crying that she wants her mother. What disorder do you think is being expressed?
separation anxiety disorder
T. is 10 years-old and is brought in for evaluation. His mother says that he will void in the toilet, but he won't use the bathroom to pass a stool. When asked, his mother states that he goes outside, in his room, in the living room, and once at school in the closet. What disorder is this mother describing?
Encopresis, elimination disorder
Your colleague is sitting next to you taking the NCLEX examination. You notice she is restless, fidgeting, and is asking to use the bathroom every half-hour. You speculate your friend is experiencing:
mild anxiety
M., is 8 years-old, and is brought in for evaluation of bedwetting. Mother describes this as an ongoing, every night, despite no drinks after 7 pm and going to the bathroom before going to bed. This disorder is termed:
Enuresis, elimination disorder
J. has paid for and registered to take the Bar examination on three separate occasions. Each time, he walks in the room, takes his assigned seat, and is handed the materials. He looks at the materials and gets up and runs out of the room. What level of anxiety does J experience with the Bar exam?
panic
Which of the following characteristics would an effective nurse have?
Sensitivity to cultural differences
What has been the traditional focus of health care providers?
treatment of disease
Which of the following would be an example of a collaborative practice model?
The nurse and the physician discussing and jointly making clinical decisions
Nurses play an important role in providing health education to patients. Who is ultimately responsible to maintain and promote health?
patients
A nurse is preparing to teach a patient how to administer in insulin injection. One of the major variables that influence a patient's readiness to learn is:
culture
The nurse is caring for a terminally ill patient. The physician has ordered a large dose of narcotic per IV infusion. The patient's respiratory rate has decreased from 16 to 10 breaths/min. What action should the nurse take?
Report the decreased respiratory rate to the physician
Nursing diagnoses can be best defined as:
Health problems that are amenable to resolution by nursing actions
A nurse is applying at a clinic that offers therapeutic abortions. This procedure contradicts the nurse's personal beliefs. The nurse feels unable to care for these patients objectively. What is the nurse's ethical obligation to these patients?
The nurse should make the choice to decline this position
A terminally ill patient has requested a "do not resuscitate" (DNR) order. The family of the patient is strongly opposed to the patient's request. What is the responsibility of the nurse?
all of the above
Which of the following would correctly define a living will?
A legal document that specifies the patient's wishes before hospitalization
Which of the following is considered a nursing implementation?
Monitor for peripheral edema twice a day
Which of the following is considered a contradiction to the nurse's duty of nonmaleficence?
Refuse to administer pain medication as ordered
Which of the following applies to the power of attorney?
Another individual has been identified to make decisions on behalf of the patient
Which of the following must be done prior to making a nursing diagnosis?
Collect and analyze data
AS an RN, you observe a colleague, while on duty, drinking alcohol. Once this has been witnessed, what professional nurse role comes into play?
duty to report
The patient was given the wrong medication and asks the nurse if there was an error made in the medication. Which of the following principles would apply if the nurse gives an accurate response?
veracity
Family members pull you out of the patient's room as they were leaving. They tell you that he abused each of them while they were young. They appear angry. Your ability to put that aside and objectively provide care is an example of what ethic?
Beneficence
Your patient is of a different religion and morally it opposes your religious beliefs. Your ability to not pass judgment on your patient and continue with your own beliefs is an example of what ethic?
Autonomy
The role of the RN is guided by the:
State board of nursing
Professional issues for nursing are addressed by the:
ANA