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A nurse is caring for a client who has dementia. The client states to the nurse,
"Everyone wants to kill me." Which of the following responses should the nurse make? -
ANSWERS-"You must feel very frightened to think someone wants to hurt you."
A community mental health nurse is planning strategies to address substance use by
adolescents. Which of the following interventions should the nurse plan as a method of
primary prevention? - ANSWERS-Provide a presentation at area high school on
resisting peer pressure for substance use.
A nurse is preparing to apply wrist restraints on a client who is threatening to harm
others and has not responded to less invasive interventions. Which of the following
actions should the nurse plan to take? - ANSWERS-Document the clients behavior
every 15 min while the restraints are in place.
, A nurse is caring for a client who has schizophrenia. The client states, "My internal
organs have turned to stone." The nurse should document this finding as which of the
following types of delusion? - ANSWERS-Somatic
A nurse is completing an admission assessment for an adolescent client who has
depression. The nurse should identify which of the following findings as the priority? -
ANSWERS-The client gave his favorite possessions to friends.
A nurse enters a clients room and observes that the client is agitated and pacing
rapidly. The client looks at the nurse and says, "Back off. Leave me alone." Which of the
following statements should the nurse make? - ANSWERS-"I will give you space if you
calm down. Tell me what is causing you to feel so tense."
A nurse in an emergency department is caring for an 18-month-old toddler who has a
fractured left femur. Which of the following statements by the toddler's parent should
cause the nurse to suspect child abuse? - ANSWERS-"My child was riding a bicycle
and fell off."
A nurse in a mental health facility is reviewing confidentiality requirements with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates
an understanding of the information? - ANSWERS-"I should keep the clients information
private even after a client dies."
A nurse at an acute mental health facility is caring for a client who has acute mania due
to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see
the provider immediately. Which of the following responses should the nurse make? -
ANSWERS-"You must be very upset about something to want to see your provider in
the middle of the night."
A nurse is caring for a client who has depression and started taking paroxetine one
week ago. The client states to the nurse, "My family would be better off without me."
Which of the following responses should the nurse make? - ANSWERS-"You sound
upset. Are you thinking of hurting yourself?"
A nurse is conducting a counseling session with a client who has a substance use
disorder. The client repeatedly asks personal questions about the nurse. Which of the