A client says to a nurse, “Get

A client says to a nurse, “Get down. They can see you; I will never get out of here alive. “What 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 3. A client makes all these statements in this initial assessment. According to Maslow theory which one indicates a problem that a nurse should address first You ashamed of gray hairs I wish my daughter would see me more often I am staying at shelter temporarily I am coughing and wheezing. 4. A well-nourished 16-year-old client is being discharged for slipped femoral epiphysis. The client is hostile, demanding, and manipulative and frequently refuses to follow activity plans that the client helped develop. Which approach by a nurse would be appropriate for handling this behavior a. Disregarding the client’s behavior b. Asking the client if he understands why the client engages in this pattern of behavior c. Adhering to the agreement and confronting the client with the effects of behavior d. Complying with the client requests. 5. A client who has dementia looks bewildered when told by a nurse, “Brush your teeth’ which action should the nurse take a. Brush the client’s teeth b. Rephrase the instructions c. Show the client the toothbrush d. Try again later 6. Which behavior of a 17yr. old age high school would most likely suggest low if esteem A. volunteering at the local hospital b. Socializing primarily with family members c. Tutoring elementary children in mathematics d. Being critical of their own parents 8. Which statement, if made by a 6yr old who is being admitted to the hospital should alert a nurse of neglect I’m going to miss going to school “Who is going to help mommy set the table for supper? “Who is going to take care of my baby sister while I’m here “I need a bag to put my dirty clothes in” 9. A client who was admitted to a nursing home 2 weeks ago is depressed and refuses to participate in the units activities what action should a nurse take a. Allow the client to stay in the client’s room b. Accompany the clients to the activity c. Inform the client that the units routine is being upset d. Tell the client that food will be withheld until the client attends activities 10. Which should a nurse ask when assessing a client for evidence of alcoholism a. “What alcoholic beverages do you drink b. How much alcohol do you drink each week c. When did you first start drinking alcohol d. Where do you usually drink alcohol 12. A nurse works with a depressed client in a long-term facility. Which action by the nurse would be most therapeutic for the client. a. Tell the client to be more cheerful b. Postpone talking with the client until the client can be sociable c. Observe the client after meals to detect induced vomiting d. Let the client gets exercise 14. A nurse approaches to assist a client out of bed for the first time after the client abdominal surgery. The client says, Stay away from me. You might drop me, “Which action by the nurse should be used initially. a. Tell the client that the nurse has done this procedure many times b. Acknowledge that the client’s fear is understandable c. Continue to carry out the procedure d. Obtain assistance 15. A 16-year-old student says to a school nurse. “I don’t think I should have to pick up my little brother after school. I want to go to the mall with my friends. “Which stage of development, according to Erikson is the student demonstrating a. Intimacy vs Isolation b. Identity vs role diffusion c. Industry vs inferiority d. Initiative vs guilt 16. Seventy-two hours after a client admission a nurse observed that the client is having visual hallucinations, agitations and restlessness, and is perspiring. Which condition should the nurse suspects that the client is exhibiting Manic Hypertensive crisis Delirium tremors Tardive dyskinesia 17. A client is admitted to the hospital for surgery to remove the larynx. Which preoperative action by a nurse will decrease the client’s postoperative active stress a. Teach the client exercises to prevent postoperative complications b. Establish a means of communication with the client c. Provide a instructions of the surgical procedure to the client d. Refer the client to a support group 18. A client is having chemotherapy following surgery to remove cancer of the uterus. The client says to a visiting nurse. Its no use things won’t get better, “Which response by the nurse would be therapeutic a. You seem discouraged about your treatment b. Things will get better, it takes time c. You are not helping yourself by being so negative d. The treatment is tough, but people do recover 19. A 13 yrs. old girl visits a clinic, reporting a sore throat. Which observation by a nurse would suggest that the client has anorexia nervosa. a. Acrocyanosis b. Amenorrhea c. Achlorhydria d. Agnosia 20. A client who is on bed rest has been waiting all morning for a bed bath yells, “How can anyone get well around here? There is frustration for a minute and nothing can be done about it. “Which response by a nurse would be most likely to calm the client a. This hardy the way to go about getting sympathy b. In a hospital we have to put first thing first c. I came as soon as I could, but my other clients are sicker and could not wait d. I guess I would also feel put upon if made to feel helpless 21. A nurse enters a room and finds a client crying, the client says, My neighbor called and said my dog died. I had Crosby for 12 years. I am so upset that I was not there. He was my best friend. “Which response would be most comforting? a. Its sad when you lose something so close to you b. You can always get another dog c. I recently lost a pet, I know how you feel d. I can’t believe you don’t have friends 22. A crying student tells a school nurse that the student’s best friend hates the student. According to Maslow which need is the student expressing a. Self actualization b. Security c. Self esteem d. Love and belonging 23. A nurse enters the room of post mastectomy client at 9.00am and observes that the client is sitting in a chair with curtains closed and the lights off, staring at the floor. Which nursing note would demonstrate objective documentation of the client’s behavior a. Appear depressed today b. Sitting in darkened room c. Expected post-surgical depression notes d. Grieving loss of body part 24. A nurse in a nursing home is feeling initiated at a client who is incoherent and often met, which response would best help the nurse to deal with the feelings of irritation Recognize that it is wrong to feel irritated with clients and act in a pleasant manner Pretend to enjoy changing the client’s clothes Ask the client why she behaves the way she does Acknowledge the feelings and discussing them with a trusted staff member 25. On the day after mastectomy a client has crying spells. The husband concerned about his wife’s weeping, takes a nurse aside and I don’t know what to do. I wish I could help her, “Assuming that the husband could carry out all of these actions, which suggestion would be most helpful to the client a. Explain to his wife the negative affect her crying has on her b. Remain with his wife quietly, even when she cries c. Tell his wife some news from home d. Coach his wife to consider future plans with him 26. Which statement by a child illustrates Erikson stage of autonomy vs shame and doubt a. Don’t let the teddy bear bite me b. I am going to wear this today c. Help me d. There is a monster in there 27. A severely depressed client says to a nurse. There is no reason for me to continue living, which response by the nurse would be therapeutic There is every reason to continue living What about your family Other people are much more off than you Are you thinking of suicide 28. Which goal is the priority for a client who is experiencing a panic attack a. The client remains safe b. The client experiences less anxiety c. The client identifies precipitates to panic attacks d. The client recognizes anxiety symptoms 29. Which action should a nurse take if the nurse suspects that a 3 yr. old child is being physically abused a. Report the child to social services to possible child abuse b. Determine who is abusing the child c. Verify that the child has been abused d. Inform the parents that they will be closely monitored. 30. A hospitalized client which is having hemodialysis is thought to be suicidal. A nurse plan to instruct that 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 hurting yourself The nurses provide the treatment for all of the clients We are just following orders that were given by the nurse manager 31. A client says to a nurse. How do you deal with your family? What do you say when everyone is demanding attention once? I feel so pressured “Which response made by the nurse is therapeutic You should remind them that you are only one person, and they need to be more patient I just walk away when I feel that others are pressuring me Let’s talk more about how you can manage these pressures I would turn them out and do whatever I think is important. 32. On the first postoperative day following a colostomy a nurse initiates colostomy teaching with a client. The client says, this is disgusting. I don’t want to touch it. “Which response by a nurse would be appropriate. You will be going home soon, and you will need to care for yourself. My supervisor will be angry with both of us, I don’t show you how to care for your colostomy I see that you are not interested now but I will leave this written information in case you feel up to looking at it later. I am putting this colostomy care video in the VCR for you to watch 33. An elderly client from a nursing home is admitted to the ambulatory department for cataract surgery. While waiting on a stretcher the client begins hovering and shaking the side rails. Which actions should a nurse give priority to. Explain to the client that the client’s behavior is upsetting other in the walking area Administer the client prescribed sedative Assess the client orientation Put a screen around the client’s stretcher 34. Which observation, if made repeatedly of a colleague client is suggestive that the colleague has a substance abuse problem a. The colleague’s clients are lethargic b. The colleague’s clients report unrelieved pain c. The colleague’s clients report long waits for service d. The colleague’s clients require longer hospital stays 35.Which measure should a nurse plan for a client who had electroconvulsive therapy (ECT) thirty minutes ago a. Encourage the client to drink oral fluids b. Monitoring the client blood pressure c. Encouraging the client to communicate verbally d. Monitoring the client pulse current level 36. If a client is receiving treatment for depression which observation is the best indicator of improvement a. The client smiled more frequently b. The client discusses plans to return to work c. The client talks in detail about suicidal thoughts d. The client makes eye contact with staff. 37. A client who has antisocial personality disorder says to a nurse, Why did you take away my belt? I am not really suicidal, I only said that in the emergency room so they would admit me. Now my pants are falling down. How am I supposed to feel better about myself when I can’t even keep my pants up?. Which response made by nurse is therapeutic a. These are the rules for all clients on this unit b. Many clients try to harm themselves here on the unit c. All psychiatric clients are a risk for self-harm d. Everyone’s pants are falling down. We can give you a safety pin 38. A client in a long-term treatment facility has a compulsive ritual that is manifested by counting to 15 every minute a nurse approaches. Which action by a nurse would be therapeutic. a. Interrupt the client while the client is counting b. Inform the client that the behavior wastes valuable time c. Promise the client a reward for omitting the counting d. Include the clients in setting limits on the behavior 39. A client on a surgical unit is in padded wrist restraints. Which measure should the nurse include in the client’s care plan a. Removing the restraints once on each shift b. Providing range of motion exercises to all extremities bed c. Assessing circulation in the upper extremities at 30 mins intervals d. Monitoring blood pressure q 1h 40. Which goal is the priority for a client who to be discharged after alcohol detoxication a. The client agrees to stop drinking after discharge b. The client identifies situations associated with alcoholism c. The client plans to join a peer support group d. The client speaks about family issues related to alcohol abuse 41. A client who has a history of panic attacks says to a nurse. I feel like I am crawling out of my skin, I am so anxious. “Which response from the nurse is therapeutic a. If you sit quietly it will go away b. How long have you been feeling this way c. Have you been taking deep breath d. I will sit here with you 42. A client who is receiving haloperidol for acute psychosis drooling and hand tremors, and has a shuffling gait. The client was prescribed these medications on a prn basis. Which medication should a nurse administer a. Lorazepam b. Benzotrophine c. Haloperidol decanoate d. Haloperidol elixir 43. A client does not make eye contact with a nurse during the initial interview. Which response made by the nurse is appropriate. a. Remind the client that eye contact is important when speaking b. Ask the client why he/she does not make eye contact c. Observe if the client makes eye contact when speaking with others d. Understanding that the lack of eye contact is a manifestation of a psychiatric problem 44. Which action does a nurse frequently have to take when working with a depressed client a. Take extra time to compensate for the clients slow movement b. Cope with the client sarcasm and verbal attacks c. Explain away the client many unrealistic suggestions for improving service d. be aware of the clients attempts to use flattery to gain special privileges 45. 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 the client will have a reduction in panic attack which interpretation made by the nurse is accurate a. The family response decreases the clients need to manage the panic attacks b. The family response indicates an understanding that the client has too many pressures c. The family response indicates a recognition of previous inadequate support d. The family response increases the likelihood that the clients panic attacks will be cured 46. Which instruction should a nurse include when teaching a client about prescribed paroxene. a. Take this medication at bedtime so it does not interfere with your meals b. Stop this medication if you feel sleepy because this indicates toxicity c. Change your position slowly until your body gets used to this medication d. Limit your fluid intake to enchance the serum concentration of this medication 47. A client is late for meals because of elaborate rituals. Which understanding should a nurse have when planning care for this client a. If the client gets involved in meal planning the rituals will decrease b. If the rituals are interrupted the client’s anxiety level will increase c. If the nurse uses behavior modification consistently with the rituals will decrease d. If the rituals continue the client’s anxiety level will increase 48. A 5yr. old client on the pediatric unit is running up and down the hall which intervention would be appropriate a. Telephone the child’s parent or guardian to come stay with the child b. Notify the nursing supervisor c. Inform the child that there will be no dessert if the running continues d. Tell the child that running is not allowed in the hospital 49. Which direction would be best understood by a client who is agitated and has a short attention span due to dementia Time for lunch Dinner is ready in the dining room. Everyone is going to eat now Come with me, we are having roast chicken and all the trimmings because its thanksgiving Thanksgiving dinner is ready in the dining room. We are going to have a real feast like the Puritans did 50. A client who has bipolar disorder is admitted to the hospital after stopping medications at home. The client is loud and hyperactive and has flight of ideas. Which approach should a nurse focus on first a. Communicating clearly with the client b. Reducing unit stimuli c. Decreasing the client’s hyperactivity d. Improving client medication compliance 51. A nurse plans to increase a client who is receiving risperidone for manifestations of the extra pyramidal side effects of diathesis which side effect should the nurse plan to monitor for ? Drowsiness Restlessness Dry mouth Dizziness 52. Which action should a nurse do to prepare clients for tests and procedures Emphasize the importance of the procedure Describe the sensory experiences to be expected during the procedure Minimize any unpleasant aspects or dangers associated with the procedure Stress how frequently the procedure is used 53. A student nurse makes all of these comments to a client. Which one should the student’s instructor recognize is judgmental You look attractive wearing that style dress This is the third time you have completed that you are not married If you stop your medication, you will get sick again Again you are saying that you don’t like your job 54. 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 mechanisms a. Denial b. Sublimation. c. Displacement d. Rationalization 55. A client says to a nurse. I am afraid I am going to die. “The nurse knows that the client has terminal illness. Which response by the nurse shows acceptance of the client’s point of view We would not let that happen You are feeling scared What are your beliefs about death Are you being unnecessarily gloomy 56. Which goal should a nurse recognize as the highest priority for a client who has anorexia nervosa The client fluid and electrolyte status is stable The client body weigh is within ideal range The client identifies healthy diet recommendation for age The client acknowledges having an eating disorder 57. A parent tells a nurse. My three year of child talks to an imaginary friend. Which response if made by the nurse is based on a correct of understanding of Piaget theory of cognitive development Three-year-old children have imaginary friends. There is no need for intervention at this time. This sounds like your child is hearing voices. Arrange for an immediate psychiatric evaluation It sounds as if your child is lonely. Setting up more frequent play dates should help Three-year-old children need a lot of virtual stimulation. Try talking to your child more frequently. 58. A client on the surgical unit says that “people are out to get his savings each time a test of treatment is ordered. In addition, to the surgical problem, the client has diagnosis of paranoid schizophrenia. Which precautions should a nurse take when caring for this client. a. Offer evidence to disprove the suspicions b. Use explicit words to prevent misunderstanding c. Ask the client to give his reasons for seeking help from people he distrusts d. Agree that unnecessary tests are sometimes ordered 59. A client tells a nurse, “I don’t want to leave the hospital, I feel safe here. Which response should the nurse make You will feel safe at home. It just takes some time You will have to leave. You are not in danger You will change your mind as you get better You and I can talk about what helps you feel safe here 60. A nurse says to a client, “I am sorry I did not get your sheet smooth, but you are so heavy you make wrinkles that I can’t pull out. Which defense mechanism does the comments exemplify a. Denial b. Rationalization c. Introjection d. Compensation 61. 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 a. Reduce the amount of salt that you ingest each day b. Take this medication on an empty stomach c. Drink at least eight glasses of fluids daily d. Avoid any foods that contain tyramine 62. A client tearfully tells a nurse about a recent family fight. Which response made by the nurse is therapeutic You should get out of your home situation immediately I will tell you how I handled a similar situation Tell me more about how disagreements are settled in your family Families that fight usually have more psychiatric problems 63. Which beverage if consumed several times daily by a client who is taking a monoamine oxidase inhibitor are depressant medication indicates a need for additional instructions Orange juice Hot cocoa Tap water Decaffeinated tea 64. Which manifestation should a nurse expect to identify in a client who has depression a. Powerlessness and anorexia b. Pressured speech and irritability c. Irrational fears and diarrhea d. Perceptual disturbances and weight gain 65. 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 a. I will be coming to the laboratory to have my blood drawn b. I can’t stop this medication when I feel better c. I will avoid foods that contain tyramine d. I am glad there is a cure for me 66. A client comes to a nurse in the emergency department and whispers, you see that man over there? He is flirting with me. Make him stop or I will have his head. The nurse notices that the man who “flirted” seems to be completely involved in comforting a baby. Which action by the nurse would be therapeutic Take the complaining client to another area of the emergency department Recognize that this complain is designed to get the nurse to care for the complaining client immediately Assure the complaining client that the person indicated is not the least bit interested Grip the complaining client’s arm and indicate that every effort will be made to provide protection. 67. A 5-year-old child who is scheduled for surgery tell a nurse about a fantasy in which the child’s hospital bed turns into a boat that salt away with the child on it. At other times the child reveals others in other cases. Which of these understanding should the nurse have about this child’s active fantasy life It is evidence of reality testing that is inadequately developed for the child’s age It allows the child to relieve some of the child’s fears It indicates that the child has heard too many fairy tales It sacrifices the child’s dependency need 68. Which behavior identified in a client who has chronic low self-esteem indicates improvement The client cleans the dining room after meals The client initiates a conversation with a peer The client accepts all required unit group activities The client reports having more energy 69. A five-year-old child is having blood drain. Which behavior identified in the client should a nurse recognize as expected based on Piaget’s theory of cognitive development. a. The child says, look how red it is. I must be special b. The child says, Will I die If I have no blood left c. The child says it does not hurt me at all d. The Child says, how long will this take 70. Which manifestation, identified in a client should a nurse recognize as a suggestive of alcohol withdrawal ??? a. Drowsiness and cravings b. Ataxia and confusion c. Sweating and tremors d. Respiratory depression and bloating 71. Which measure should a nurse include when planning to use a behavior therapy approach with a client a. Confronting the client’s inappropriate behaviors b. Observing the client behavior on a continual basis c. Providing reinforcers for the desired behaviors d. Ignoring the client inappropriate behaviors 72.A 70-year-old client has just been admitted to a hospital with a fractured hip. Which approach by a nurse would most likely be helpful in implementing preoperative teaching a. Repeat information as necessary b. Limit the advice to discharge needs c. Plan one inclusive session d. Postpone teaching until after surgery 73. 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 drunk. Which interpretation and action made by the nurse are therapeutic a. The client is manipulative, set consistent limits with the client b. The client is rationalizing focus on the actual results of the client’s behavior c. The client is confused provide reality-based responses d. The client is in denial have the patient identify effects of alcohol use in his life 74. A client has a nursing diagnosis of disturbed thought processes as evidenced by paranoid delusions. Which intervention should a nurse use Logically explain that the client delusions are not real Focus in the underlying reasons for the delusions Interact with the client on real, here – and – now topics Convey acceptance of all of the client’s thoughts 75. Which measure should a nurse include in the care plan for a client who has dementia a. Creating a stimulating environment for the client b. Keeping the client room distraction free c. Maintaining a consistent routine for the client d. Finding new activities for the client each day

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