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  • 1. Saunders NCLEX Questions Ch 71-76Chapter 71 1. The Nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. In spite of the client’s efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? A. Exploring the client’s ability to function B. Exploring the client’s potential for self harm C. Inquiring the client’s perception of appraisal of neighbor’s death D. Inquiring about and examining the client’s feelings that may block adaptive coping . Answer= D.Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the clients feelings. Option 1 and 2 do not directly address the clients feelings. Option 3 is more of an assessment of question. 2. A client who has just been sexually assaulted is quiet and calm. The nurse analyzes this behavior as indicating which defense mechanism. 1. Denial 2 Projection 3.Rationalization 4.IntellectualizationANSWER: 1Rationale:
  • 2. RATIONALE: Denial is refusal to admit a painful reality and maybe a response by a victim of sexualabuse. Projection is transferring ones feelings, thoughts, and unacceptable ideas and traits to someoneelse. Rationalization is justifying the unacceptable attributes about one-self. Intellectualization is theexcessive use of abstract thinking to decrease painful thinking. 3. Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client’s blood, the client begins to shout “you’re all vampires. Let me out of here!” the appropriate nursing response is which the following? 1: What makes you think that I am a vampire? 2: “ I’ ll leave and come back later for your blood” 3: I an not going to hurt you, I am going to help you 4: It must be frightening to think that others want to hurt you?Answer: 4Rationale:3. Answer:Rationale: Option 4 identifies the therapeutic communication technique of restatement. Although it is atechnique that has a prompting component to it, it repeats the clients major theme and provides theperception of the problem from the clients perspective. Option 1 allows the client to direct the discussionwhen it needs to be more focused at this point. Option 2 uses reflection that simply repeats the clientslast words to prompt further discussion. Option 3 focuses on the number of nights rather than the specificproblem of sleep. 4. Unresolved feelings related to loss most likely may be recognized during which phase of therapeutic nurse-client relationship. 1: Working
  • 3. 2: Trusting 3: Orientation 4: Termination Answer =4Rationale: Rationale: In the termination phase, the relationship comes to a close. Ending treatment may sometimes be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. 5. A client with a diagnosis of major depression who has attempted suicide says to the nurse, “I should have died. I‘ve always been a failure. Nothing ever goes right for me.” The therapeutic response to the client is 1: I don’t see you as a failure 2: YOU HAVE EVERYTHING TO LIVE FOR 3: FEELING LIKE THIS IS ALL PART OF BEIBG ILL 4“YOU HAVE BEEN FEELING LIKE A FAILURE FOR A WHILE” Answer= 4Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2 and 3 block communication because they minimize the clients experience and do not facilitate exploration of the clients expressed feelings. 6. The community health nurse visits a client at home visits a client at home. The client states, “I haven’t slept at all the last couple of nights”. Which response by the nurse illustrates a therapeutic communication technique for this client?
  • 4. 1: “Go on” 2 Sleeping 3” You’ rehaving difficulty sleeping 4 “Sometimes, I have trouble sleeping too.” Answer 3.Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of restating. Options 1, 2, and 4 block communication because they minimize the clients experience and do not facilitate exploration of the clients expressed feelings 7. A client admitted to the mental unit is experiencing disturbed to thought processes and believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? 1: Using open-ended questions and silence 2: Focusing on self-disclousure regarding food preference 3 Identifying the reasons that the client may not wanrt to eat. 4:OFFERING OPINIONS ABOUT THE NECESSITY OF ADEQUATE NUTRITIONRationale:
  • 5. 8. A client is admitted to the mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, “Let me out. There is nothing wrong with me. I don’t belong here.” The nurse analyzes this behavior as:A: DenialB ProgestionC: Regration.D: RationalizationRationale: 9. The supervisor reprimands the nurse in charge of the nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies, this behavior is an example of 1 : DENIAL 2: PROJECTION 3: REGRESSION 4: DISPLACMENTRationale: 10. The client says to the nurse, “I’ am going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all I’ m the one who’s dying.” The therapeutic response by nurse is . 1. “Have you you shared your feelings with your family”
  • 6. 2. “I think we should talk more about your anger with you family” 3. “ YOUR FEELING ANGRY THAT YOUR FAMILY CONTINUES TO HOPE FOR YOU TO BE CURED” 4. Well, it sounds like your being pretty pessimistic. After all, years ago, people died of pneumoniaRationale:11. The nurse employed in a mental health unit is assigned to care for a client admitted to theunit 2 days ago. ON review of the client’s record, the nurse notes that the admission was avoluntary admission. Based on this type of admission, the nurse anticipates which of thefollowing? 1. The client will resist treatment measures. 2. The client will be angry and will refuse care. 3. The client’s family will resist treatment measures. 4. The client will participate in the planning of the care and treatment plan.Rationale:12. A nurse enters a client’s room, and the client is demanding release from the hospital. Thenurse reviews the client’s record and notes that the client was admitted 2 days ago for treatmentof an anxiety disorder and that the admission was a voluntary admission. Which of the followingactions will the nurse take? 1. Contact the physician. 2. Call the client’s family.
  • 7. 3. Persuade the client to stay for a few more days. 4. Tell the client that discharge is not possible at this time.Rationale:13. A client has been admitted to the mental health unit. On admission assessment, the nursenotes that the client was admitted by involuntary status. Based on this type of admission, thenurse would most likely expect the client” 1. Presents a harm to self 2. Requested the admission 3. Consented to the admission 4. Provided written application to the facility for admissionRationale:14. The nurse is preparing the client for the termination phase of the nurse-client relationship.The nurse prepares to implement which nursing task appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomesRationale:
  • 8. 15. During the termination phase of the nurse-client relationship, the clinic nurse observes thatthe client has made several sarcastic remarks and has an angry affect. The most appropriateinterpretation of the behavior is that the client: 1. Needs to be admitted to the hospital 2. Needs to be referred to the psychiatrist as soon as possible. 3. Requires further treatment and is not yet ready to be discharged. 4. Is displaying typical behaviors that can occur during termination.Rationale:16. The nurse is provided care to a client admitted to the hospital with a diagnosis of acuteanxiety disorder. While conversing with the client, the client says to the nurse, “I have a secretthat I want to tell you. You won’t tell anyone about it, will you?” The appropriate nursingresponse is which of the following? 1. “No, I won’t tell anyone.” 2. “I cannot promise to keep a secret.” 3. “If you tell me the secret, I will tell it to your doctor.” 4. “If you tell me the secret, I will need to document it is your record.”Rationale:17. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocerystore. The neighbor says to the nurse, “How is Carol doing? She is my best friend and is seen inyour clinic every week.” The appropriate nursing response is which of the following? 1. “I cannot discuss any client situation with you.”` 2. “If you want to know about Carol, you need to ask her yourself.”
  • 9. 3. “I’m not suppose to discuss this, but because you are my neighbor, I can tell you thatshe is doing great!” 4. “I’m not suppose to discuss this, but because you are my neighbor, I can tell you thatshe really has some problems!”Rationale:18. A home health nurse is talking to the spouse of a client taking an antidepressant. The spousesays, “Now that my husband is responding to the antidepressant, the suicidal risk is over and youcan stop making these home visits.” After analyzing this statement, which of the following is theappropriate nursing response? 1. “I need to continue with my visits. Your comment reflects the lack of knowledge thatthis disease runs in families.” 2. “I agree with you. Clients who want to kill themselves are only suicidal for a limitedtime. No one can feel self-destructive forever.” 3. “I agree with you. The suicidal threats were really attention seeking. Continuing tovisit would reinforce your husband’s use of manipulation.” 4. “I need to continue with my visits. Most suicides occur within 3 months afterimprovement begins because the client now has the energy to carry out the suicidal intentions.”Rationale:19. The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nursenotes that an informed consent has not been obtained for the procedure. On review of the record,the nurse notes that the admission was an involuntary hospitalization. Based on this information,the nurse determines:
  • 10. 1. That the physician will provide the informed consent 2. That an informed consent does not need to be obtained 3. That an informed consent should be obtained from the family 4. That an informed consent needs to be obtained from the clientRationale:20. The client was admitted involuntarily to the mental health unit because of episodes ofextremely violent behavior. The client is demanding to be discharged from the hospital and thenurse does not allow the client to leave. Which of the following represents the legalramifications associated with the nurse’s behavior? 1. The nurse will be charged with assault. 2. The nurse will be charged with slander. 3. The nurse will be charged with imprisonment. 4. No charge will be made against the nurse because the nurse’s actions are reasonable.Rationale:Chapter 721. The client asks the nurse about milieu therapy. The nurse responds, knowing that the primaryfocus of milieu therapy can best be described as which of the following? 1. A form of behavior modification therapy 2. A cognitive approach to changing behavior 3. A living, learning, or working environment 4. A behavioral approach to changing behavior
  • 11. Rationale:2. The nurse is caring for a client with a phobia who is being treated for the condition. Theclient is introduced to short periods of exposure to the phobic object while in a relaxed state. Thenurse understands that this form of behavior modification can best be described as: 1. Milieu therapy 2. Aversion therapy 3. Self control therapy 4. Systematic desentizationRationale:3. A client with an eating disorder is planning to attend group meetings with OvereatersAnonymous, and the nurse describes this group to the client. The nurse determines that the clientneeds additional information if the client states which of the following about this self help group 1. “The leader is a nurse or psychiatrist.” 2. “The members provide support to each other.” 3. “People who have a similar problem are able to help others.”
  • 12. 4. “It is designed to serve people who have a common probe.”Rationale: 4 The nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following? 1. Ask the client to leave. 2. Refer the client to another group. 3. Tell the client to stop monopolizing 4. Thank the client for the contribution and tell him or her to allow others a chance to contribute.Rationale: 5. A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse’s role in the termination stage of group development is to: 1. Encourage problem-solving 2. Encourage accomplishment of the group’s work. 3. Acknowledge the contributions of each group member. 4. Encourage members to become acquainted with one another.Rationale:
  • 13. 6 All treatment team members are seen as equally important in helping clients meet their treatment goals. This type of therapy approach is: 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Rational emotive therapyRationale: 7 An 18-yeal old woman is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa. A cognitive behavioral approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to: 1. Provide a supportive environment. 2. Examine intrapsychic conflicts and past issues. 3. Emphasize social interaction with clients who withdraw. 4. Help the client identify and examine dysfunctional thoughts and beliefs.Rationale:8 A client with major depression is considering cognitive therapy. The client asks the nurse,“How does this treatment work?” The nurse responds and tells the client that: 1. “This type of treatment will help you relax and develop new coping skills.” 2. This type of treatment helps you confront your fears by gradually exposing you to them.”
  • 14. 3. “This type of treatment helps you examine how your past life has contributed to your problems.” 4. “This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties.Rationale:9. The client is preparing to attend a Gambler’s Anonymous meeting for the first time. Theprototype used by this group is the 12-step program developed by Alcoholics Anonymous. Thenurse tells the client that the first step in the 12-step program is which of the following. 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with friends who are gamblers.Rationale:Chapter 731. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania.The symptom presented by the client that requires the nurse’s immediate intervention is theclient’s: 1. Outlandish behaviors and inappropriate dress 2. Nonstop physical activity and poor nutritional intake 3. Grandiose delusions of being a royal descendent of King Arthur 4. Constant, incessant talking that includes sexual innuendoes and teasing the staff
  • 15. Rationale:2. A client who is delusional says to the nurse, “The federal guards were sent to kill me. “Thenurse’s best response is: 1. “I don’ts believe this is true.” 2. “The guards are not out to kill you.” 3. “What makes you think the guards were sent to hurt you?”4. “I don’t know anything about the guards. Do you feel afraid that people are trying to hurt you?”Rationale:3. A woman comes into the emergency room in a severe state of anxiety following a car accident.The appropriate nursing intervention is to:1. Remain with the client.2. Put the client in a quiet room.3. Teach the client deep breathing.4. Encourage the client to talk about their feelings and concerns.Rationale:4. A male client with delirium becomes disoriented and confused in his room at night. The bestinitial nursing intervention is to:1. Move the client next to the nurse’s station.2. Use an indirect light source and turn off the television.3. Keep the television and a soft light on during the night.
  • 16. 4. Play soft music during the night, and maintain a well-lit room.Rationale:5. The nurse is performing an assessment on a client with dementia. Which data gathered duringthe assessment indicate a manifestation associated with dementia?1. Confabulation2. Improvement in sleeping3. Absence of sundown syndrome4. Presence of personal hygienic careRationale:6. The nurse is discharging a client with a history of command hallucinations to harm self or others. The nurse provides instruction s to the client about interventions for hallucinations and anxiety and determines that the client understands the instructions if the client states:1. “My medications won’t make me anxious”.2. “I’ll go to support group and talk so that I don’t hurt anyone”.3. “I won’t get anxious or hear things if I get enough sleep and eat well”.4. “I can call my therapist when I’m hallucinating so that I can talk about my feelings and plansand not hurt anyone”.Rationale:7. The nurse develops a nursing diagnosis of self-care deficit for an older client with dementia.Which of the following is an appropriate goal for this client?1. The client will function at the highest level of independence possible.2. The client will complete all activities of daily living independently within 1-hour time frame.
  • 17. 3. The nurse will be admitted to a long –term care facility to have activities of daily living needsmet.4. The nursing staff will attend to all the client’s activities of daily living needs during thehospital stay.Rationale:8. The nurse is caring for a male client diagnosed with catatonic stupor. The client is lying on thebed with his body pulled into a fetal position. The appropriate nursing intervention is which ofthe following?1. Ask direct questions to encourage talking.2. Leave the client alone and intermittently check on him.3. Sit beside the client in silence with occasional open-ended questions.4. Take the client into the dayroom with other clients so that they can help watch him.Rationale:9. The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursingdiagnosis formulated for the client is thought processes, disturbed related to paranoia. Informulating nursing interventions with the members of the health care team, the nurse providesinstructions to:1. Increase socialization of the client with peers.2. Avoid laughing or whispering in front of the client.3. Begin to educate the client about social supports in the community.4. Have the client sign a release of information to appropriate parties so that adequate data can beobtained for assessment purposes.Rationale:
  • 18. 10. A client is admitted to the mental health unit with a diagnosis of depression. The nursedevelops a plan of care for the client and includes which appropriate activity in the plan?1. Reading, and writing most of the day2. Several activities from which the client can choose3. Nothing until the client asks to participate in milieu4. A structured program of activities in which the client can participateRationale:11. When planning the discharge of a client with chronic anxiety, the nurse directs the goals atpromoting a safe environment at home. the appropriate maintenance goal should focus on whichof the following?1. Ignoring feelings of anxiety2. Identifying anxiety-producing situations3. Continued contract with a crisis counselor4. Eliminating all anxiety from daily situationsRationale:12. The client is unwilling to go out of the house for fear of “doing something crazy in public.”Because of this fear, the client remains homebound, expect when accompanied outside by thespouse. Based on this data, the nurse determines that the client is experiencing:1. Agoraphobia2. Social phobia3. Claustrophobia4. HypochondriasisRationale:
  • 19. 13: A nurse is conducting a group therapy session during the season, a client with maniaconsistently talks and dominates the group session, and her behavior is disrupting the groupinteraction. The nurse would initially: 1. Ask the client to leave the group session 2. Ask another nurse to escort the client out of the group session 3. Tell the client that she would not be able to attend any future group sessions 4. Tell the client that she needs to allow other clients ion the group time to talkRationale:14: A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many testsare performed, and there seems to be no organic reason why this client cannot see. The nurselater learns that the client became blind after witnessing a hit-and-run car accident, when afamily of three was killed. The nurse suspects that the client may be experiencing a: 1. Psychosis 2. Repression 3. Conversion 4. Dissociative disorderRationale:15: The manic client announces to everyone in the day room that a stripper is coming to performthis evening. When the nurse firmly states that this would not happen, the manic client becomesverbally abusive and threatens physical violence to the nurse. Based on the analysis on thissituation, the nurse determines that the appropriate action would be to: 1. Orient the client to time, person, and place 2. Tell the client that the behavior is not appropriate
  • 20. 3. Escort the manic client to her room, with assistance4. Tell the client that smoking privileges are revoked for 24 hoursRationale:16: The nurse is planning activities for a client who has bipolar disorder with aggressive socialbehavior. Which of the following activities would be most appropriate for this client? 1. Chess 2. Writing 3. Pin pong4. BasketballRationale:17: A client is admitted to the hospital with a diagnosis if depression, severe single episode. Thenurse accesses the client and identifies a nursing diagnosis of nutrition; less than bodyrequirement, imbalance related to poor nutritional intake. The appropriate nursing interventionrelated to this diagnosis is: 1. Weigh the client three times per week before breakfast
  • 21. 2. Explain to the client the importance of a good nutritional intake 3. Schedule brief nursing interactions with the client during several meals in which small portions are offered 4. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possibleRationale:18: The depressed client verbalizes feelings of low self-esteem and self-worth typified bystatements such as “I am such failure. I can’t do anything right.” The best nursing responsewould be to: 1. Tell the client that this is not true, that we all have a purpose in life 2. Identify recent behaviors or accomplishments that demonstrate the clients skill 3. Reassure the client that you know how the client is feeling and that things will get better4. Remain with the client and sit in silence. This will encourage the client to verbalize feelingsRationale:
  • 22. 19: A client with a diagnosis of major depression, recurrent, with psychotic features, is admittedto the mental health unit. To create a safe environment for the client, the nurse most importantlydevices a plan of care that deals especially with the clients: 1. Self –care deficit 2. Imbalance nutrition 3. Deficient knowledge 4. Disturbed thought processRationale: 20: The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. Theclients’ speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse’simmediate priority of care is to: 1. Provide safety for the client and other clients on the unit 2. Provide the clients on the unit with a sense of comfort and safety 3. Assist the staff in caring for the client in the controlled environment 4. Offer the less stimulated area to calm down and gain controlRationale:Chapter 741: The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium? 1. Hypotension, ataxia, hunger
  • 23. 2. Stupor, agitation, muscular rigidity 3. Hypotension, coarse hand tremors, agitation 4. Hypertension, changes in level of consciousness, hallucinationRationale:2: The spouse of a client admitted to the mental health unit for alcohol withdrawal says to thenurse “I should get out of this bad situation.” The most helpful response by the nurse would be 1. ‘Why don’t you tell your husband about this’ 2. ‘What do you find difficult about this situation’ 3. ‘This is not the best time to make that decision’ 4. ‘I agree with you. You should get out of this situation.’Rationale:3. The home health nurse visits a client at home and determines that the client is dependent ondrugs. Which of the following assessment questions would assist the nurse to provide appropriatenursing care? 1. “Why did you get started on these drugs!” 2. "How much did you use and what effect does it have on you" 3. “ How long did you think you could take these drugs without someone finding out!” 4. The nurse does not ask any questions for fear that the client is in denial and will throwthe nurse out of the home.Rationale:
  • 24. 4. A female client with anorexia nervosa is a member of of a pre-discharge support group. Theclient verbalizes that she will like to buy some clothes, but her finances are limited. Groupmember have brought some used clothe to the client to replace the clients old clothes. The clientbelieve that the new clothes were much too tightand has reduced her calories daily. The nurse analyzes this behavior as: 1. Normal behavior 2. Evidence of the clients disturbed body image. 3. Regression as the client is moving toward the community 4. Indicative of the client’s ambivalence about hospital dischargeRationale:5. The nurse determines that the wife of an alcoholic client is is benefiting from attending an Al-Anon group when the nurse hears the wife say: 1. "I no longer feel that i deserve the beating my husband inflicts on me." 2. “My attendance at the meetings has helped me to see that I provoke my husband’sviolence.” 3. “I enjoy attending the meetings because they get me out of the house and away frommy husband”
  • 25. 4. “ I can tolerate my husband’s destructive behavior now that I know they are commonwith alcoholics”Rationale:6. A hospitalized client with a history of alcohol abuse tells the nurse, "I am living now. I have togo. I dont want any more treatment. I have things that i have to do right away." The client hasnot been discharged. In fact,the client is scheduled for an important diagnostic test to beperformed in 1 hour. After the nurse discussesthe clients concern with the client, the client dresses and begins to walk out of the hospital room.The appropriate nursing action is to: 1. Call the nursing supervisor. 2. Call security to block all exits areas 3. Restrain the client until the physician can be reached 4. Tell the client that the client cannot return to this hospital again if the client leavesnow.Rationale:7. The nurse is preparing to perform an admission assessment on a client with a diagnosis ofbulima nervosa, and a nursing student will be observing the nurse. The nurse ask the studentabout the expected assessment findings and determines that the student needs to research thedisorder further if the student states that which of thefollowing is a characteristic finding? 1. Dental decay 2. Loss of tooth enamel 3. Electrolyte imbalances
  • 26. 4. Body weight well below ideal range.Rationale:8. The nurse is caring for a female client who was admitted to the mental health unit recentlyfor anorexia nervosa. The nurse enters the clients room and notes that the client is engaged in arigorouspush-ups.which nursing action is appropriate? 1. Interrupt the client and weight her immediately 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to completeher exercise program 4. Tell the client that she is not allowed to exercise rigorouslyRationale:9. The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior ofthe client and understands that the clients with anorexia nervosa manages anxiety by: 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations. 4. Having the need always to make the right decisionsRationale:
  • 27. 10. The client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bedroom. A newly admitted client will be assigned to this clients room. Which of the followingclients would be an appropriate choice as this clients room-mate? 1. A client with pneumonia 2. client receiving a diagnostic tests. 3. A client who thrives on managing others 4. A client who could benefit from the client’s assistance at mealtimeRationale:Chapter 751. The nurse is planning for a client being admitted to a nursing unit who attempted suicide.Which of the following priority nursing interventions will the nurse include in the plan of care? 1. One-to-one suicide precautions. 2. Suicide precautions with 30 minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediatelyRationale:2. The emergency room nurse is caring for a client who has been identified as a victim ofphysical abuse. In planning care for the client, which of the following is the priority nursingaction?
  • 28. 1.Adhering to the mandatory abuse reporting laws. 2. Notifying the case worker of the family situation. 3. Removing the client from any immediate danger. 4. Obtaining treatment for the abusing family member.Rationale:3. The emergency room nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situationRationale:4. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels “as though the rape just happened yesterday,” even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1. “You need to try to be realistic. The rape did not just occur.” 2. “It will take some time to get over these feelings about your rape.” 3. “Tell me more about the incident that causes you to feel like the rape just occurred.” 4. “What do you think that you can do to alleviate some of your fears about being raped again”?Rationale:5. The nurse in the emergency department is caring for a young female victim of sexual assault. The client’s physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as: 1. Signs of depression
  • 29. 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admissionRationale:6. The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which of the following is unrealistic as a short-term initial goal? 1. Physical wounds will heal. 2. The client will participate in the treatment plan. 3. The client will verbalize feelings about the event. 4. The client will resolve feelings of fear and anxiety related to the rape trauma.Rationale:7. Which of the following is the best approach for the nurse to use in crisis counseling? 1. Reassuring 2. Passive listening 3. Explore early life experiences 4. Active, with focus on current situationRationale:8. A client comes to the clinic after losing all personal belongings in a hurricane. The nurse develops a nursing diagnosis of Coping, ineffective. Which of the following is the least realistic goal for this client? 1. The client will develop adaptive coping patterns. 2. The client will identify a realistic perception of stressors. 3. The client will express and share feelings regarding the present crisis.
  • 30. 4. The client will stop blaming himself or herself for the lack of insurance.Rationale:9. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by: 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client’s home 4. A recent rape episode experienced by the clientRationale:10. The nurse is conducting an initial assessment on a client in crisis. When assessing the client’s perception of the precipitating event that led to the crisis, the appropriate question to ask is: 1. “With whom do you live?” 2. “Who is available to help you?” 3. “What leads you to seek help now?” 4. “What do you usually do to feel better?”Rationale:11. The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the nurse considers which of the following? 1. A crisis state indicates that the individual is suffering from a mental illness. 2. A crisis state indicates that the individual is suffering from an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis.
  • 31. 4. A client’s response to a crisis is individualized and what constitutes a crisis for one person may not constitute a crisis for another person.Rationale:12. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client? 1. “You need to stop that behavior now.” 2. “You will need to be placed in seclusion.” 3. “You seem restless; tell me what is happening.” 4. “You will need to be restrained if you do not change your behavior.”Rationale:13. During a conversation with a depressed client on an inpatient unit, the client says to the nurse, “My family would be better off without me.” The nurse’s best response is: 1. “Have you talked to your family about this?” 2. “Everyone feels this way when they are depressed.” 3. “You will feel better once your medication begins to work.” 4. “You sound very upset. Are you thinking of hurting yourself?”Rationale:14. The nurse has been observing a client closely who has been displaying aggressive behaviors.The nurse observes that the behavior displayed by the client is escalating. Which nursingintervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client’s behavior.
  • 32. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance with the client.Rationale:15. Which behavior observed by the nurse indicates a suspicion that a depressed femaleadolescent client may be suicidal? 1. The client runs out of the therapy group, swearing at the group leader and runs to herroom. 2. The client gives away a prized CD and a cherished autograph picture of the performer. 3. The client becomes angry while speaking on the telephone and slam down the receiver. 4. The client gets angry with her roommate when the roommate borrows the client’s clothes without asking.Rationale:16. A client is admitted to the mental health unit following a serious attempt of suicide byhanging. The nurse’s most important aspect of care is to maintain client safety. This isaccomplished best by: 1. Requesting that a peer remain with the client at all times. 2. Removing the client’s clothing and placing the client in a hospital gown. 3. Assigning a staff member to the client who will remain with the client at all times. 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed.Rationale:
  • 33. 17. The police arrive at the emergency room with a client who has seriously lacerated bothwrists. The initial nursing action is to: 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encouraged and assist the client to ventilate feelings.Rationale:18. The nursing care plan indicates a nursing diagnosis of violence, self-directed, risks forsuicidal ideations with a plan. An expected outcome of this plan of care would be that the client: 1. Displays less anxiety and agitation. 2. Establishes a relationship with staff and peers. 3. Develops adequate coping and problem-solving skills. 4. Denies suicidal ideation and identifies options to deal with stressors.Rationale:19. A client is admitted to the hospital with a nursing diagnosis of grieving, dysfunctional relatedto the loss of a spouse. The client progresses well and is approaching discharge. Which of thefollowing is an appropriate outcome for this nursing diagnosis? 1. The client reports three additional coping strategies. 2. The client verbalizes stages of grief and plans to attend a community grief group. 3. The client verbalizes connections between significant losses and low self esteem. 4. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide.Rationale:
  • 34. 20. The moderately depressed client who was hospitalized 2 days ago suddenly begins smilingand reporting that the crisis is over. The client says to the nurse, “I’m finally cured”. The nurseinterprets this behavior as a cue to modify the treatment plan by: 1. Suggesting a reduction of medication. 2. Allowing increased “in-room” activities. 3. Increasing the level of suicide precautions. 4. Allowing the client off-unit privileges as needed.Rationale:Chapter 76.1. The nurse is performing a follow-up teaching session with a client discharged 1 month ago.The client is taking fluoxetine (Prozac). What information would be important for the nurse toobtain during this client visit regarding the side effect of this medication? 1. Cardiovascular symptoms 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweatingRationale:2. The client who has been taking buspirone (BuSpar) for 1 month returns to the clinic for afollow-up assessment. The nurse determines that the medication is effective if the absence ofwhich manifestation(s) has occurred. 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusionsRationale:
  • 35. 3. A client taking lithium carbonate (Eskalith) reports vomiting, abdominal pain, diarrhea,blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse interprets thislevel as: 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normalRationale:4. The home health nurse visits the client. The client gives the nurse a bottle of clomipramine(Anafranil). The nurse notes that the medication has not been taken by the client in 2 months.What behaviors observed in the client would validate noncompliance with this medication? 1. Complaints of insominia 2. Complaints of hunger and fatigue 3. Aa pulse rate less than 60 beats/min 4. Frequent hand washing with hot soapy water.Rationale:5. The hospitalized client has begun taking bupropion ( Wellbutrin) as an antidepressant agent.The nurse monitors this client for which adverse effect indication that the client is taking anexcessive amount of medication? 1. Constipation 2. Seizure activity
  • 36. 3. Increased weight 4. Dizziness when getting uprightRationale:6. The client’s medication sheet contains an order for sertraline hydrochloride (Zoloft). To ensuresafe administration of the medication, the nurse would administer the dose: 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depressionRationale:7. The client with schizophrenia has been started on medication therapy with clozapine(Clozaril). The nurse assesses the results of which laboratory study to monitor for adverse effectsfrom this medication? 1. Platelet count 2. Blood glucose level 3. White blood cell count 4. Liver function studiesRationale:
  • 37. 8. a client is scheduled for discharge and will be taking Phenobarbital (Luminal) for an extendedperiod of time. The nurse would place highest priority on teaching the client which of thefollowing points that directly relates to client safety? 1. Take the medication only with meals 2. Take medication at the same time each day. 3. Use a dose container to help prevent missed doses. 4. Avoid drinking alcohol while taking this medicationRationale:9. The 26 years-old female client with schizophrenia has been prescribed chlorpromazinehydrochloride (Thorazine). The client calls the mental health clinic and tells the nurse that herurine has become dark. The client has no other urinary symptoms. The nurse tells the client: 1. That this indicates medication toxicity 2. To seek treatment for urinary tract infection 3. To increase intake of acid-ash foods and liquids 4. That this is an expected side effect of the medicationRationale:10. A client is receiving fluphenazine (Prolixin) daily. The nurse would teach the client to dowhich of the following to minimize common side effects of this medication? 1. Monitor the temperature daily 2. Use hard sour candy or sugarless gum 3. Eat snacks at midmorning and at bedtime
  • 38. 4. Have the blood pressure checked once a weekRationale:11. The nurse is describing the medication side effects to a client who is taking oxazepam(Serax). The nurse incorporates in discussions with the client the need to” 1. Consume a low-fiber diet 2. Increase fluids and bulk in the diet 3. Rest if the heart begins to beat rapidly 4. Take antidiarrheal agents if diarrhea occurs.Rationale:12. The nurse is administering risperidone (Risperdal) to a client who is scheduled to bedischarged. Prior to discharge, which of the following should the nurse teach the client? 1. Get adequate sunlight 2. Avoid foods rich in potassium 3. Continue driving as usual 4. Get up slowly when changing positionsRationale:
  • 39. 13. A client receiving lithium carbonate (Eskalith) complains of loose watery stools anddifficulty walking. The nurse would expect the serum lithium level to be which of the following? 1. 0.7 mEq/L 2. 1 mEq/L 3. 1.3 mEq/L 4. 1.8 mEq/LRationale:14. The nurse is teaching a client who is being started on imipramine hydrochloride (Tofranil)about the medication. The nurse informs the client that the maximum desired effects may: 1. Start during the first week of administration 2. Not occur for 2 to 3 weeks of administration 3. Start during the second week of administration 4. Not occur until after 2 months of administrationRationale:15. The client receiving tricyclic antidepressants arrives at the mental health clinic. Whichobservation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for this past week. 2. Client arrives at the clinic neat and appropriate in appearance
  • 40. 3. Client complains of not being able to “do anything” anymore 4. Client report sleeping 12 hours per night and 3 to 4 hours during the day.Rationale:16. A client begins to experience extrapyriamidal side effects from an antispsychotic medication.The nurse anticipates that the physician will prescribe which of the following to treat thiscondition? 1. Haloperidol (Haldol) 2. Benztropine (Cogentin) 3. Prochlorperazine (Compazine) 4. Chlorpromazine (Thorazine)Rationale:17. The nurse notes that a client diagnosed with schizophrenia is moving her mouth, protrudingher tongue, and grimacing as she watches television. The nurse determines that the client isexperiencing: 1. Torticollis 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndromeRationale:
  • 41. Alternate Item Format: Multiple ResponseA hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. Thenurse instructs the client to avoid consuming which foods while taking this medications. (Selectall that apply) 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal cookiesRationale: