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26 Cards in this Set
- Front
- Back
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A nurse is assessing the health status of an older adult client. Although the client denies a problem, the caregiver explains that the client is alert and oriented but consistently has an unkempt appearance, body odor, and soiled clothing. The nurse understands that the client’s behavior is likely related to which of the following? |
Select one: a. Exhibiting evidence of asymptomatic pathology.
b. Manifesting typical early symptoms of delirium.
c. Experiencing side effects from a medication.
d. Restricting activities in response to disease symptoms.
Answer
d. Restricting activities in response to disease symptoms. Delirium is characterized by an abrupt disturbance in consciousness, typically manifesting as disorientation, first to time, then place, and lastly to person. Disorientation and confusion may be markedly worse at night and during the early morning. Neglect of personal hygiene is not an early characteristic of delirium, but disorientation may cause a decline in functional health status. |
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During an assessment, an adolescent client whispers to the nurse, "I have to tell you something, but you have to promise you won't tell anyone else." Which of the following is the most appropriate response for the nurse to make? |
Select one: a. "I am bound by the nurse-client relationship to keep your comments private."
b. "I feel that you should share this with your parents first."
c. "I cannot make that promise if it affects your or someone else’s safety."
d. "What is said in this room stays in this room."
Answer
. "I cannot make that promise if it affects your or someone else’s safety." Nurses should not promise what they cannot do. If a client admits to behaviors that are dangerous to self or others, the nurse is obligated to report these behaviors.
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A nurse is caring for a terminally ill client of the Muslim faith and observes the client to be unconscious and having Cheyne-Stokes respirations. The family has repositioned the bed so that the client is on the right side facing toward the wall. The nurse does not question this action because of which of the following? |
Select one: a. This positioning is preferred for a client with respiratory distress.
b. This positioning has religious significance for the client and family.
c. The nurse should support the family in their efforts to make the client comfortable.
d. The religious practice of concealing the face of the dying client should be supported.
Answer
b. This positioning has religious significance for the client and family. According to Muslim teachings, it may be comforting to the dying client and family to turn the client on the right side to face Mecca. When death occurs, the body must be kept covered at all times, and it is preferred that only healthcare professionals of the same gender touch the body. In this situation, observing the position of the client would indicate that the spiritual needs of the client and family were being met.
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A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the mental health unit. The client is confused and disoriented. When developing a plan of care, which of the following would be the priority intervention for this client? |
Select one: a. Explain unit rules to the client.
b. Stabilize the client’s psychiatric needs.
c. Accept and make the client feel safe.
d. Orient the client to the unit.
Answer
c. Accept and make the client feel safe. Orienting a client to the unit is a part of any admission and is not a priority at this time because the client is confused and disoriented. |
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The nurse is assessing the family dynamics of a widow with end stage terminal cancer. Which statement made between the adult children would best indicate the need for further teaching? |
Select one: a. “It does not matter what we think, the living will says ‘do not resuscitate'.”
b. “If daddy were alive, he would be making these hard decisions, not us.”
c. “Since you are the oldest child, you have the responsibility to decide.”
d. “The doctors have told us that it is time for us to make some tough decisions.”
Answer
a. “It does not matter what we think, the living will says ‘do not resuscitate'.”
This comment is not unexpected, nor is it inappropriate. In most cases, healthcare providers ask immediate next of kin to make decisions about end of life care when the client is unable to do so. |
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A client diagnosed with schizophrenia and experiencing frequent auditory hallucinations is admitted to an inpatient psychiatric unit. Which of the following would be the most effective, initial strategy for the nurse to implement? |
Select one: a. Agree with the client that the voices are audible.
b. Ask the client to rest in a quiet area until the voices are gone.
c. Explain to the client that the hallucination is not real.
d. Ask the client to describe the components of the hallucination.
Answer
d. Ask the client to describe the components of the hallucination.
Initially, the nurse should try to understand what the voices are saying or telling the client to do. Suicidal or homicidal messages necessitate initiation of safety measures for all members of the healthcare team as well as the client. Once a client describes the hallucination or delusion, do NOT dwell on it. Rather, focus conversation on more reality-based topics.
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A client expresses to the nurse that her husband is an alcoholic and has trouble keeping a job for longer than three months. Which of the following is the nurse’s best response? |
Select one: a. "What have you done in the past to help deal with this problem?”
b. “This seems to worry you. May I contact the Hospital Chaplain?”
c. “I’m so sorry to hear that. Why do you think he drinks?”
d. “Have you tried to contact Al-Anon? I can help if you want.”
Answer
a. "What have you done in the past to help deal with this problem?” Providing a broad opening allows the client to elaborate and gives the nurse the opportunity to assess problem-solving and coping skills of the client.
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A nurse is caring for an adolescent client who is recovering from a traumatic below the knee amputation. The day after surgery, the client refuses to look at or touch the affected leg. Which of the following nursing interventions would be most beneficial to this client? |
Select one: a. Avoid discussing the amputation until the client initiates conversation.
b. Remind the client that full mobility is possible once fitted for a prosthesis.
c. Gently examine and redress the stump without frowning or grimacing.
d. Insist that the client participate in bathing and examining his affected leg.
Answer c. Gently examine and redress the stump without frowning or grimacing. Discussion about the care of the stump, pain relief, positioning, etc. is appropriate and conveys acceptance by the nurse of the altered body image. |
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A nurse is caring for an adolescent client admitted to the nursing unit three days ago. The client is withdrawn, unwilling to eat, and does not interact with the staff. The nurse correctly understands which of the following would provide the best support for this client? |
Select one: a. A visit with friends from school.
b. A call from the client’s sibling.
c. An opportunity to view a popular DVD.
d. A visit with a parent.
Answer
a. A visit with friends from school. Peers are the most important support and influential component of an adolescent’s life. According to Erikson, the development stage for this age group is “Identity vs. role confusion” and requires peer relationships and group memberships.
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During a group therapy session on a psychiatric unit, the nurse leader observes that one of the clients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation? |
Select one: a. Tell the client that the interrupting behavior must be discontinued.
b. Ask the client to speak privately with a nurse after the meeting.
c. Discuss this observation during the post-meeting evaluation.
d. Encourage another group member to reprimand the client.
Answer b. Ask the client to speak privately with a nurse after the meeting. A therapeutic milieu group aims to help increase self-esteem, decrease social isolation, encourage appropriate social behaviors, and educate clients in basic living skills. Confronting the client during the meeting could negatively affect self-esteem and increase social isolation. The behavior needs to be addressed, but not in an openly confrontational way. |
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A client comes to a mental health clinic after experiencing a crisis in which a fire destroyed the client’s home and took the life of a child. The client states, “I am unable to work or sleep and don’t see how I can go on after this.” Which of the following is the priority nursing intervention for this client? |
Select one: a. Help the client return to a pre-crisis level of functioning.
b. Enroll the client in a grief counseling program.
c. Assess the client for potential suicidal behavior.
d. Relocate the client to a more supportive environment.
Answer
c. Assess the client for potential suicidal behavior. The statement “…don’t see how I can go on after this,” requires immediate further exploration to determine whether action must be taken to protect the client from self-harm.
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A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate? |
Select one: a. Inquire about any rituals the parents would like to perform at this time.
b. Remove the infant from the room and allow the parents a period of time to grieve.
c. Gently inform the parents about the hospital procedures for handling a stillborn infant.
d. Remain in the room and answer any questions the parents may have about the stillbirth.
Answer a. Inquire about any rituals the parents would like to perform at this time. The nurse should remain in the room unless asked to leave. However, the nurse may not be prepared to answer detailed questions or provide detailed explanations. |
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Parents share with a nurse that the beloved pet cat of their preschooler died just before the child was admitted to the hospital. Which of the following statements would be characteristic for a child of this age to make about death? |
Select one: a. “It’s my fault Fluffy died because I let him out.”
b. “What happens to cats after they die?”
c. “Fluffy didn’t really die. He’s just sleeping.”
d. “All cats get old and die. And Fluffy too.”
Answer
c. “Fluffy didn’t really die. He’s just sleeping.” The preschooler has no clear concept of time and usually believes death is temporary and reversible. The dead person (or animal) may have attributes of the living (e.g. ‘sleeping’, ‘eating’, ‘breathing’), or may be dead to a degree (e.g. ‘a little bit dead’).
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A nurse is admitting a client diagnosed with schizophrenia. In order to establish a therapeutic nurse-client relationship with the client, the nurse’s initial actions should include which of the following? |
Select one: a. Develop a contract
b. Maintain consistency
c. Provide confidentiality
d. Establish trust
Answer
d. Establish trust A priority goal during the first few encounters with a client diagnosed with schizophrenia is to provide an atmosphere in which trust can grow.
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The nurse is attempting to comfort parents who just experienced the death of their premature infant. The parents are angry and blaming the nurses and doctors for the death of their child. Which of the following is the most appropriate nursing intervention? |
Select one: a. Grant time for the parents and family to hold and be with their infant.
b. Provide a more detailed explanation for why their infant passed away.
c. Remind the parents that the nurses and doctors did all they could for their infant.
d. Refer the parents to grief support group to deal with the loss of their infant.
Answer a. Grant time for the parents and family to hold and be with their infant. Medical explanations at this stage in the grieving process may be overwhelming to parents. Instead of offering explanations, the nurse should allow the parents to verbalize their feelings regarding the loss of their baby. |
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A client has recently been diagnosed with inoperable lung cancer and has been referred to hospice. The nurse recognizes that the client has successfully dealt with the anticipated outcome of the disease when the client states which of the following? |
Select one: a. “I just don’t want to talk with anyone right now.”
b. “I plan on planting a vegetable garden next year.”
c. "If I can live, I will never smoke a cigarette again.”
d. “I have reviewed my will and advance directives.”
Answer d. “I have reviewed my will and advance directives.” This statement indicates the client is in the acceptance or coping phase of grieving. |
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An adult is seen in the healthcare provider’s office with multiple bruises and lacerations consistent with physical abuse. During the nursing assessment, the client reports that the injuries were intentionally inflicted by the spouse and verbalizes fear that it will happen again. Which of the following statements would indicate that the nurse’s initial counseling has been effective? |
Select one: a. “I’ll tell my spouse that I have spoken with you and that I have decided we need to start counseling soon as a couple.”
b. “The next time the hitting starts, I will tell my spouse to stop immediately or I’ll be forced to call the police.”
c. "I’ll go home and pack my bag, putting it out in the open so my spouse understands that I’m serious about leaving.”
d. "I will take some money, clothes, and important papers to my parents’ home and go there if things start to get bad again.”
Answer d. "I will take some money, clothes, and important papers to my parents’ home and go there if things start to get bad again.” During the violent episode, it is inadvisable to confront the perpetrator who is already out of control. The primary concern should be getting the victim to a place of safety. |
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A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. Which of the following may negatively affect the client’s adjustment to living with family members? |
Select one: a. The family is insisting on maintaining financial control for the client.
b. Older clients often recover more quickly when encouraged to interact with family.
c. The family is actively involved in the discharge plans.
d. The client is unable to complete all ADLs.
Answer
a. The family is insisting on maintaining financial control for the client. While it might be appropriate for family members to assist with financial matters, unless client is declared incompetent there is no need for them to maintain complete control. This may be perceived as very threatening to the client.
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A client who is suffering from delusions states, “I can’t stay in group today. I am expecting the governor to be here any minute!” The nurse leading the group responds, “I understand, but right now it is time for group and we expect everyone to attend.” Which of the following explains why the nurse’s statement would be considered therapeutic? |
Select one: a. It articulates what is expected without reinforcing the delusion
b. It sets limits on manipulative behavior without creating a confrontation
c. It demonstrates to all group members that the nurse is in control
d. It discourages other group members from trying to avoid group
Answer
a. It articulates what is expected without reinforcing the delusion This response is clear and matter-of-fact; it does not draw attention to the client in the group situation, does not argue with the client, does not reinforce the delusion, but accomplishes the intent of getting the client to stay in the meeting
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A client has been prescribed lithium carbonate to control the symptoms of bipolar II disorder. The client presents to the clinic reporting symptoms of lethargy, generalized discomfort, and a poor appetite. Which of the following would be the nurse’s priority action? |
Select one: a. Assess the client to rule out possible flu syndrome
b. Question the client for concomitant alcohol use
c. Ask the client if they have experienced episodes of mania
d. Prepare the client for lab work to measure lithium levels
Answer
d. Prepare the client for lab work to measure lithium levels. The client is exhibiting symptoms of relapse of bipolar II disorder: a hypomanic episode and lithium levels should be assessed first for therapeutic level. Lithium requires careful dosage adjustment to reach and maintain therapeutic levels; the level will be very important for evaluating the client’s clinical picture.
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A nurse is planning care for a client newly admitted to an inpatient mental health unit for treatment of a gambling addiction. The client is having difficulty concentrating and is worried about the future. Which initial intervention will maximize the client’s success for recovery? |
Select one: a. Administer an anti-anxiety medication to the client.
b. Recommend the client participate in group discussion.
c. Arrange for the client to attend Gamblers Anonymous.
d. Suggest the client replace work out on the treadmill.
Answer a. Administer an anti-anxiety medication to the client. Clients with non-substance abuse often have few meaningful personal relationships. Group discussion may provide for human interaction but most likely will not lead to long term relationships. Therefore, personalized self-help programs work most effectively for clients with gambling addictions. |
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A nurse has completed medication teaching for flouxetine with a client recently diagnosed with recurring panic attacks. Which of the following statements made by the client indicates a need for further teaching? |
Select one: a. “It may take up to four weeks or longer before flouxetine takes full effect.”
b. “I can eat whatever I want while I am taking flouxetine.”
c. “When my panic attacks go away and I feel better I must continue taking flouxetine.”
d. “I need to monitor my blood sugar closely while I am taking flouxetine.”
Answer b. “I can eat whatever I want while I am taking flouxetine.” Fluoxetine should not be stopped without consulting a health care provider and it is important to continue taking the medication even when symptoms are relieved to prevent relapse of sypmptoms. |
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A nurse has completed medication teaching for disulfiram with an adult child of an alcoholic parent. Which of the following statements made by the adult child indicate an understanding of the nurse’s teaching? |
Select one: a. “Dad may have to take this medication for a long time until he gains self-control over alcohol use.”
b. “I am so glad my dad has agreed to take this drug, I want it to cure his drinking problem.”
c. “Before being discharged from the hospital, dad will have at least one supervised alcohol-drug reaction.”
d. "My dad’s last drink was eight hours ago, so he may take his the first dose immediately.”
Answer a. “Dad may have to take this medication for a long time until he gains self-control over alcohol use.” Disulfiram should never be administered until the client has abstained from alcohol for at least 12 hours in order to avoid symptoms of interaction between the drug and alcohol in the client’s system. Effects of interaction include nausea, vomiting, weakness, and hypotension |
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A nurse has completed medication teaching regarding methylphenidate with a client. Which of the following client statements indicates an understanding of the nurse’s teaching? |
Select one: a. “Weight gain is common if I take methylphenidate long term.”
b. “Avoiding afternoon doses of methylphenidate will help me sleep better.”
c. “Methylphenidate is a safe drug with very few side effects.”
d. “If I don’t like how I feel on methylphenidate, I may stop it at any time.”
Answer b. “Avoiding afternoon doses of methylphenidate will help me sleep better.” Prolonged therapy with methylphenidate is associated with weight loss because of appetite suppression. |
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An adult client is seen in the emergency department and is accompanied by a sibling who reports that the client is incapable of performing self-care activities. The client states, “Freeze thumping lasting circus going.” The client appears suspicious and reports hearing threatening voices. The nurse recognizes that the client is exhibiting signs of which disorder? |
Select one: a. Bipolar disorder I b. Generalized anxiety disorder c. Dissociative fugue d. Paranoid schizophrenia
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An adult client is seen in the emergency department and is accompanied by a sibling who reports that the client is incapable of performing self-care activities. The client states, “Freeze thumping lasting circus going.” The client appears suspicious and reports hearing threatening voices. The nurse recognizes that the client is exhibiting signs of which disorder? |
Select one: a. Bipolar disorder I
b. Generalized anxiety disorder
c. Dissociative fugue
d. Paranoid schizophrenia
Answer
d. Paranoid schizophrenia Paranoid schizophrenia is characterized by auditory or visual hallucinations, and perhaps threatening voices. The statement made by the client indicates word salad which is a jumble of words that are meaningless to the listener. This alteration in speech is considered a positive symptom of schizophrenia.
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