NUR 104 MIDTERM AND FINAL EXAM EXCELSIOR COLLEGE 2025/2026 WITH ALL 300
QUESTIONS AND CORRECT ANSWERS GRADED A/ NURSING NUR 104 EXAM LATEST
VERSION 1 ANSWERS
(BRAND NEW!!)
A client with a psychiatric disorder was voluntarily admitted and now wishes to be discharged from
the hospital, against medical advice. Which aspect would be most important for the nurse to
determine in this situation?
A. ability to care for self
B. degree of danger to self and others
C. level of psychosis
D. intended compliance with aftercare
B. degree of danger to self and others
During a private conversation, a client with borderline personality disorder asks the nurse to keep his
secret and then displays multiple, self-inflicted, superficial lacerations on his forearms. What is the
most appropriate way for the nurse to respond?
A. "That's it! You're on suicide precautions."
B. "I'm going to tell your physician. Do you want to tell me why you did that?"
C. "Tell me what type of instrument you used. I'm concerned about infection."
D. "The team needs to know when something important occurs in treatment. I need to tell the
others, but let's talk about it first."
D. "The team needs to know when something important occurs in treatment. I need to tell the
others, but let's talk about it first."
A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight
with a parent. Which nursing intervention would be most helpful?
A. Examine the relationship between feelings and eating.
B. Discuss the importance of therapy for the entire family.
C. Encourage the client to avoid certain family members.
D. Don't fight with parents.
A. Examine the relationship between feelings and eating.
,A nurse is assisting with the development of a plan of care for a client with anorexia nervosa. Which
action would the nurse expect to implement as part of the plan?
A. restricting family visits until the client begins to eat
B. providing client privacy during meals
C. reinforcing a strict refeeding plan for the client
D. encouraging the client to exercise vigorously
C. reinforcing a strict refeeding plan for the client
A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't
changed." Which concept should be explored with this client?
A. further education
B. conflict resolution
C. career development
D. personal development
D. personal development
Which nursing action is most appropriate for the nurse to utilize when trying to diffuse a client's
impending violent behavior?
A. Helping the client identify and express feelings of anxiety and anger
B. Involving the client in a quiet activity to divert attention
C. Leaving the client alone until the client can talk about his or her feelings
D. Placing the client in seclusion
A. Helping the client identify and express feelings of anxiety and anger
A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent
assessment finding associated with early alcohol withdrawal would the nurse expect to find?
A. Heart rate of 120 to 140 beats/minute
B. Heart rate of 50 to 60 beats/minute
C. Blood pressure of 100/70 mm Hg
D. Blood pressure of 140/80 mm Hg
A. Heart rate of 120 to 140 beats/minute
The nurse is caring for a client with bulimia nervosa. Which observation by the nurse is life-
threatening and should be reported to the health care provider immediately?
A. serum calcium 10.1 mg/dL
B. heart rate 56 beats/minute
C. serum potassium 2.9 m Eq/L
,D. respiratory rate 16 breaths/minute
C. serum potassium 2.9 m Eq/L
A client is struggling with alcohol dependence. Which communication strategy is most effective for
the nurse?
A. Speak briefly and directly.
B. Avoid blaming or lecturing the client.
C. Confront feelings and examples of perfectionism.
D. Determine if nonverbal communication will be more effective.
B. Avoid blaming or lecturing the client.
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell
cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which
action would the nurse incorporate to best promote compliance by this client?
A. The contract should be written abstractly.
B. The contract should be written by the client alone.
C. The contract should be written jointly by the client and nurse.
D. The contract should be written jointly by the physician and nurse.
C. The contract should be written jointly by the client and nurse.
A client with alcoholism has just completed a residential treatment program. Which client statement
reflects that treatment has been effective?
A. "I am glad my family will no longer be dysfunctional."
B. "I need ongoing support to remain sober."
C. "I am so happy to be free from alcoholism."
D. "I can now drink an alcoholic beverage once in a while without problems."
B. "I need ongoing support to remain sober."
The nurse is caring for a 15-year-old client whose parent expresses concern about the client's weight
loss and constant dieting. Which client comment requires immediate nursing intervention?
A. "I am trying to keep my weight down because it's important to my health as an athlete."
B. "I don't like the food my parents cook, so I eat fast food when I go out with friends."
C. "I am so fat compared to other kids who are my age."
D. "I diet around my monthly periods; otherwise I feel like I get very bloated."
C. "I am so fat compared to other kids who are my age."
, A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who
tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa,
throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary
importance?
A. Talking with the client's family about his angry feelings
B. Performing an assessment for tardive dyskinesia
C. Learning to effectively express needs to staff and others
D. Demonstrating control over aggressive behavior
D. Demonstrating control over aggressive behaviour
A client with anorexia nervosa attended psychoeducational sessions on principles of adequate
nutrition. Which statement by the client indicates the education was effective?
A. "I should eat while I'm doing things to distract myself."
B. "I should eat all my food at night just before I go to bed."
C. "I should eat small amounts of food slowly at every meal."
D. "I should eat only when I'm with my family and trying to be social."
C. "I should eat small amounts of food slowly at every meal."
A client is brought to the emergency department after being beaten by her husband, a prominent
attorney. The nurse caring for this client understands which factor about abuse?
A. Open boundaries are common in violent families.
B. Violence usually results from a power struggle.
C. Domestic violence and abuse span all socioeconomic classes.
D. Violent behavior is a genetic trait passed from one generation to the next.
C. Domestic violence and abuse span all socioeconomic classes.
A client is admitted to a medical-surgical unit for treatment of an orthopedic injury. In addition to
this admitting diagnosis, the nurse notes that the client has a history of borderline personality
disorder with episodes of cutting/self- mutilation. Which type of behavior would the nurse expect to
be present due to this self-mutilation history? (Select all that apply.)
A. no presence of cuts or burns found during assessment
B. no unexplained frequent injuries
C. knife or razor in purse or bag
D. insistence on wearing long-sleeved shirt even in warm temperatures
E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing
C. knife or razor in purse or bag
D. insistence on wearing long-sleeved shirt even in warm temperatures
E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing
A client addicted to alcohol begins individual therapy with a nurse. Which goal should be
a priority for the client?
A. learning to express feelings
QUESTIONS AND CORRECT ANSWERS GRADED A/ NURSING NUR 104 EXAM LATEST
VERSION 1 ANSWERS
(BRAND NEW!!)
A client with a psychiatric disorder was voluntarily admitted and now wishes to be discharged from
the hospital, against medical advice. Which aspect would be most important for the nurse to
determine in this situation?
A. ability to care for self
B. degree of danger to self and others
C. level of psychosis
D. intended compliance with aftercare
B. degree of danger to self and others
During a private conversation, a client with borderline personality disorder asks the nurse to keep his
secret and then displays multiple, self-inflicted, superficial lacerations on his forearms. What is the
most appropriate way for the nurse to respond?
A. "That's it! You're on suicide precautions."
B. "I'm going to tell your physician. Do you want to tell me why you did that?"
C. "Tell me what type of instrument you used. I'm concerned about infection."
D. "The team needs to know when something important occurs in treatment. I need to tell the
others, but let's talk about it first."
D. "The team needs to know when something important occurs in treatment. I need to tell the
others, but let's talk about it first."
A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight
with a parent. Which nursing intervention would be most helpful?
A. Examine the relationship between feelings and eating.
B. Discuss the importance of therapy for the entire family.
C. Encourage the client to avoid certain family members.
D. Don't fight with parents.
A. Examine the relationship between feelings and eating.
,A nurse is assisting with the development of a plan of care for a client with anorexia nervosa. Which
action would the nurse expect to implement as part of the plan?
A. restricting family visits until the client begins to eat
B. providing client privacy during meals
C. reinforcing a strict refeeding plan for the client
D. encouraging the client to exercise vigorously
C. reinforcing a strict refeeding plan for the client
A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't
changed." Which concept should be explored with this client?
A. further education
B. conflict resolution
C. career development
D. personal development
D. personal development
Which nursing action is most appropriate for the nurse to utilize when trying to diffuse a client's
impending violent behavior?
A. Helping the client identify and express feelings of anxiety and anger
B. Involving the client in a quiet activity to divert attention
C. Leaving the client alone until the client can talk about his or her feelings
D. Placing the client in seclusion
A. Helping the client identify and express feelings of anxiety and anger
A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent
assessment finding associated with early alcohol withdrawal would the nurse expect to find?
A. Heart rate of 120 to 140 beats/minute
B. Heart rate of 50 to 60 beats/minute
C. Blood pressure of 100/70 mm Hg
D. Blood pressure of 140/80 mm Hg
A. Heart rate of 120 to 140 beats/minute
The nurse is caring for a client with bulimia nervosa. Which observation by the nurse is life-
threatening and should be reported to the health care provider immediately?
A. serum calcium 10.1 mg/dL
B. heart rate 56 beats/minute
C. serum potassium 2.9 m Eq/L
,D. respiratory rate 16 breaths/minute
C. serum potassium 2.9 m Eq/L
A client is struggling with alcohol dependence. Which communication strategy is most effective for
the nurse?
A. Speak briefly and directly.
B. Avoid blaming or lecturing the client.
C. Confront feelings and examples of perfectionism.
D. Determine if nonverbal communication will be more effective.
B. Avoid blaming or lecturing the client.
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell
cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which
action would the nurse incorporate to best promote compliance by this client?
A. The contract should be written abstractly.
B. The contract should be written by the client alone.
C. The contract should be written jointly by the client and nurse.
D. The contract should be written jointly by the physician and nurse.
C. The contract should be written jointly by the client and nurse.
A client with alcoholism has just completed a residential treatment program. Which client statement
reflects that treatment has been effective?
A. "I am glad my family will no longer be dysfunctional."
B. "I need ongoing support to remain sober."
C. "I am so happy to be free from alcoholism."
D. "I can now drink an alcoholic beverage once in a while without problems."
B. "I need ongoing support to remain sober."
The nurse is caring for a 15-year-old client whose parent expresses concern about the client's weight
loss and constant dieting. Which client comment requires immediate nursing intervention?
A. "I am trying to keep my weight down because it's important to my health as an athlete."
B. "I don't like the food my parents cook, so I eat fast food when I go out with friends."
C. "I am so fat compared to other kids who are my age."
D. "I diet around my monthly periods; otherwise I feel like I get very bloated."
C. "I am so fat compared to other kids who are my age."
, A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who
tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa,
throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary
importance?
A. Talking with the client's family about his angry feelings
B. Performing an assessment for tardive dyskinesia
C. Learning to effectively express needs to staff and others
D. Demonstrating control over aggressive behavior
D. Demonstrating control over aggressive behaviour
A client with anorexia nervosa attended psychoeducational sessions on principles of adequate
nutrition. Which statement by the client indicates the education was effective?
A. "I should eat while I'm doing things to distract myself."
B. "I should eat all my food at night just before I go to bed."
C. "I should eat small amounts of food slowly at every meal."
D. "I should eat only when I'm with my family and trying to be social."
C. "I should eat small amounts of food slowly at every meal."
A client is brought to the emergency department after being beaten by her husband, a prominent
attorney. The nurse caring for this client understands which factor about abuse?
A. Open boundaries are common in violent families.
B. Violence usually results from a power struggle.
C. Domestic violence and abuse span all socioeconomic classes.
D. Violent behavior is a genetic trait passed from one generation to the next.
C. Domestic violence and abuse span all socioeconomic classes.
A client is admitted to a medical-surgical unit for treatment of an orthopedic injury. In addition to
this admitting diagnosis, the nurse notes that the client has a history of borderline personality
disorder with episodes of cutting/self- mutilation. Which type of behavior would the nurse expect to
be present due to this self-mutilation history? (Select all that apply.)
A. no presence of cuts or burns found during assessment
B. no unexplained frequent injuries
C. knife or razor in purse or bag
D. insistence on wearing long-sleeved shirt even in warm temperatures
E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing
C. knife or razor in purse or bag
D. insistence on wearing long-sleeved shirt even in warm temperatures
E. overly hesitant behavior when the nurse attempts to assist with bathing or dressing
A client addicted to alcohol begins individual therapy with a nurse. Which goal should be
a priority for the client?
A. learning to express feelings
