DETAILED QUESTIONS AND CORRECT
ANSWERS GRADED A+
●● A nurse is caring for a child who has conducted disorder and is
behaving in a destructive manner, throwing objects, and kicking others.
Which of the following therapeutic nursing interventions is the priority?
Encourage expression of feelings
Support the child's attendance at an assertiveness training group
Assist the child to perform relaxation breathing
Reduce environmental stimuli. Answer: Reduce environmental stimuli
The greatest risk to the child and others is harm. Therefore, the nurse's
priority intervention is to reduce environmental stimuli in an attempt to
de-escalate the behavior and prevent injury.
●● A nurse in a community health center is working with a group of
clients who have post-traumatic stress disorder. Which of the following
,interventions should the nurse include to reduce anxiety among the
group members?
Response prevention
Guided imagery
Aversion therapy
Light therapy. Answer: Guided imagery
Guided imagery involves assisting the client to imagine a restful and
safe place. This method is effective in reducing anxiety in clients who
have post-traumatic stress disorder.
●● A nurse is performing a cognitive assessment to distinguish delirium
from dementia in a client whose family reports episodes of confusion.
Which of the following assessment findings supports the nurse's
suspicion of delirium?
Slow onset
Aphasia
,Confabulation
Easily distracted. Answer: Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
●● A nurse is caring for an older adult client who begins to cry and
states, "I knew God would punish me and I deserve this horrible
sickness!" Which of the following responses should the nurse make?
"Why do you think you deserve this punishment?"
"Don't worry about being punished by God."
"Let's talk about what is upsetting you."
"You shouldn't say things that will upset you so much.". Answer: "Let's
talk about what is upsetting you."
The nurse is acknowledging the client's concerns and is showing a desire
to understand what the client is thinking and feeling.
, ●● A client who has a recent diagnosis of bipolar disorder is placed in a
room with a client who has severe depression. The client who has
depression reports to the nurse, "My roommate never sleeps and keeps
me up, too." Which of the following actions should the nurse take?
Move the client who has bipolar disorder to a private room
Administer sleep medication to the client who has bipolar disorder.
Move the client who has severe depression to a private room.
Administer sleep medication to the client who has severe depression..
Answer: Move the client who has bipolar disorder to a private room.
Clients who have bipolar disorder can disrupt the therapeutic milieu for
other clients. Therefore, the nurse should move this client to a private
room.
●● A nurse is caring for a group of clients. Which of the following
findings is he nurse required to report?
A client who has bipolar disorder and tested positive for genital herpes
simplex virus reports having multiple sexual partners.