N3381 STUDY EXAMS GUIDE LATEST QUESTIONS
AND ANSWERS SURE A+
✔✔During the admission assessment process, the nurse observes that a client
diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers.
The client denies oral pain or difficulty eating and does not present any concern over
the nurse's finding. The nurse recognizes the client's response as most likely the result
of which client factor?
1.Apathy
2.Impaired pain perception
3.Distrust of authority figures
4.Poor verbal communication skills - ✔✔Impaired pain perception
Rationale:Commonly, schizophrenia's effect on the pain center in the brain results in
poor pain recognition. The client is likely not experiencing oral pain to the degree that
may be felt by the individual who does not have schizophrenia. Although the remaining
options may be general factors affecting this client's perceptions and personal
interactions, they are not related to the pain perception threshold.
✔✔A client comes into the emergency department in a severe state of anxiety after a
car crash. Which is the best nursing intervention at this time?
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 his or her feelings and concerns. - ✔✔Remain with
the client.
Rationale:If left alone, the severely anxious client may feel abandoned and become
overwhelmed. Placing the client in a quiet room is also important, but the nurse must
stay with the client. Teaching the client deep breathing or relaxation is not possible until
the anxiety decreases. Encouraging the client to discuss concerns and feelings would
not take place until the anxiety has decreased.
✔✔Which is the best therapeutic approach for the nurse to use in crisis counseling?
1.Reassuring
2.Passive listening
3.Exploration of early life experiences
4.Active, with focus on the current situation - ✔✔Active, with focus on the current
situation
Rationale:During crisis counseling, the best approach for the nurse to use is an active
one, with a focus on the current situation. The remaining options would be inconsistent
with the acute needs that emerge in a crisis. Passive listening would be contrary to the
individual's acute stress and disorganization. Exploring the past would be insensitive to
the current crisis and would be exploitative of a client in acute distress. Although
reassurance may be needed, what is most important about the nurse's response in a
crisis is the need for a direct focus on immediate needs.
✔✔The nurse observes that a client with a potential for violence is agitated, pacing up
and down the hallway, and making aggressive and belligerent gestures at other clients.
Which statement would be most 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." - ✔✔"You seem
restless; tell me what is happening."
Rationale:The most appropriate statement is to ask the client what is causing the
agitation. This will assist the client to become aware of the behavior and may assist the
nurse in planning appropriate interventions for the client. Option 1 is demanding
behavior that could cause increased agitation in the client. Options 2 and 4 are threats
to the client and are inappropriate.
✔✔A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a
2-bed room. A newly admitted client will be assigned to this client's room. Which client
would be the best choice as a roommate for the client with anorexia nervosa?
, 1.A client with pneumonia
2.A client undergoing diagnostic tests
3.A client who thrives on managing others
4.A client who could benefit from the client's assistance at mealtime - ✔✔A client
undergoing diagnostic tests
Rationale:The client undergoing diagnostic tests is an acceptable roommate. The client
with anorexia nervosa is most likely experiencing hematological complications, such as
leukopenia. Having a roommate with pneumonia would place the client with anorexia
nervosa at risk for infection. The client with anorexia nervosa should not be put in a
situation in which the client can focus on the nutritional needs of others or be managed
by others because this may contribute to sublimation and suppression of personal
hunger.
✔✔A client comes to the emergency department after an assault and is extremely
agitated, trembling, and hyperventilating. What is the priority nursing action for this
client?
1.Begin to teach relaxation techniques.
2.Encourage the client to discuss the assault.
3.Remain with the client until the anxiety decreases.
4.Place the client in a quiet room alone to decrease stimulation. - ✔✔Remain with the
client until the anxiety decreases.
Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic
state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe
state of anxiety would be unable to learn relaxation techniques. Discussing the assault
at this point would increase the client's level of anxiety further. Placing the client in a
quiet room alone may also increase the anxiety level.
✔✔A client asks the nurse about the meaning of behavioral therapy. Which description
describes the purpose of behavioral therapy?
1.Fosters positive behavioral change
2.Develops structure and organizes time
3.Creates insight into maladaptive behavior
4.Decreases stress through relaxation training - ✔✔Fosters positive behavioral change
Rationale:The purpose of behavioral therapy is to create effective changes in behavior.
Developing structure and organizing time describe aspects of milieu management.
Insight is a useful outcome of psychotherapy but does not always result in behavior
change. Relaxation training is a treatment modality effective for reducing stress.
✔✔The nurse is creating a plan of care for the client who is upset following the loss of a
job and is verbalizing concerns regarding the ability to meet financial obligations. Which
problem is the basis of the client's concerns?
AND ANSWERS SURE A+
✔✔During the admission assessment process, the nurse observes that a client
diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers.
The client denies oral pain or difficulty eating and does not present any concern over
the nurse's finding. The nurse recognizes the client's response as most likely the result
of which client factor?
1.Apathy
2.Impaired pain perception
3.Distrust of authority figures
4.Poor verbal communication skills - ✔✔Impaired pain perception
Rationale:Commonly, schizophrenia's effect on the pain center in the brain results in
poor pain recognition. The client is likely not experiencing oral pain to the degree that
may be felt by the individual who does not have schizophrenia. Although the remaining
options may be general factors affecting this client's perceptions and personal
interactions, they are not related to the pain perception threshold.
✔✔A client comes into the emergency department in a severe state of anxiety after a
car crash. Which is the best nursing intervention at this time?
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 his or her feelings and concerns. - ✔✔Remain with
the client.
Rationale:If left alone, the severely anxious client may feel abandoned and become
overwhelmed. Placing the client in a quiet room is also important, but the nurse must
stay with the client. Teaching the client deep breathing or relaxation is not possible until
the anxiety decreases. Encouraging the client to discuss concerns and feelings would
not take place until the anxiety has decreased.
✔✔Which is the best therapeutic approach for the nurse to use in crisis counseling?
1.Reassuring
2.Passive listening
3.Exploration of early life experiences
4.Active, with focus on the current situation - ✔✔Active, with focus on the current
situation
Rationale:During crisis counseling, the best approach for the nurse to use is an active
one, with a focus on the current situation. The remaining options would be inconsistent
with the acute needs that emerge in a crisis. Passive listening would be contrary to the
individual's acute stress and disorganization. Exploring the past would be insensitive to
the current crisis and would be exploitative of a client in acute distress. Although
reassurance may be needed, what is most important about the nurse's response in a
crisis is the need for a direct focus on immediate needs.
✔✔The nurse observes that a client with a potential for violence is agitated, pacing up
and down the hallway, and making aggressive and belligerent gestures at other clients.
Which statement would be most 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." - ✔✔"You seem
restless; tell me what is happening."
Rationale:The most appropriate statement is to ask the client what is causing the
agitation. This will assist the client to become aware of the behavior and may assist the
nurse in planning appropriate interventions for the client. Option 1 is demanding
behavior that could cause increased agitation in the client. Options 2 and 4 are threats
to the client and are inappropriate.
✔✔A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a
2-bed room. A newly admitted client will be assigned to this client's room. Which client
would be the best choice as a roommate for the client with anorexia nervosa?
, 1.A client with pneumonia
2.A client undergoing diagnostic tests
3.A client who thrives on managing others
4.A client who could benefit from the client's assistance at mealtime - ✔✔A client
undergoing diagnostic tests
Rationale:The client undergoing diagnostic tests is an acceptable roommate. The client
with anorexia nervosa is most likely experiencing hematological complications, such as
leukopenia. Having a roommate with pneumonia would place the client with anorexia
nervosa at risk for infection. The client with anorexia nervosa should not be put in a
situation in which the client can focus on the nutritional needs of others or be managed
by others because this may contribute to sublimation and suppression of personal
hunger.
✔✔A client comes to the emergency department after an assault and is extremely
agitated, trembling, and hyperventilating. What is the priority nursing action for this
client?
1.Begin to teach relaxation techniques.
2.Encourage the client to discuss the assault.
3.Remain with the client until the anxiety decreases.
4.Place the client in a quiet room alone to decrease stimulation. - ✔✔Remain with the
client until the anxiety decreases.
Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic
state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe
state of anxiety would be unable to learn relaxation techniques. Discussing the assault
at this point would increase the client's level of anxiety further. Placing the client in a
quiet room alone may also increase the anxiety level.
✔✔A client asks the nurse about the meaning of behavioral therapy. Which description
describes the purpose of behavioral therapy?
1.Fosters positive behavioral change
2.Develops structure and organizes time
3.Creates insight into maladaptive behavior
4.Decreases stress through relaxation training - ✔✔Fosters positive behavioral change
Rationale:The purpose of behavioral therapy is to create effective changes in behavior.
Developing structure and organizing time describe aspects of milieu management.
Insight is a useful outcome of psychotherapy but does not always result in behavior
change. Relaxation training is a treatment modality effective for reducing stress.
✔✔The nurse is creating a plan of care for the client who is upset following the loss of a
job and is verbalizing concerns regarding the ability to meet financial obligations. Which
problem is the basis of the client's concerns?
