N3381 UPDATED TEST PAPER EXAMS QUESTIONS
AND ANSWERS SURE A+
✔✔Which statement by the nurse indicates a need for further teaching concerning
family violence?
1."Abusers use fear and intimidation."
2."Abusers usually have poor self-esteem."
3."Abusers often are jealous or self-centered."
4."Abusers are more often from low-income families." - ✔✔"Abusers are more often
from low-income families."
Rationale:Personal characteristics of abusers include low self-esteem, immaturity,
dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the
point at which their victims will do anything just to avoid further abuse. The statement
that abuse occurs more often in lower socioeconomic groups is incorrect.
✔✔A nursing student is assisting with the care of a client with a chronic mental illness.
The nurse informs the student that a behavior modification approach (operant
conditioning) will be used in treatment for the client. Which statement by the student
indicates a need for further information about the therapy?
1."It uses positive reinforcement."
,2."It uses negative reinforcement."
3."It increases social behaviors in the client."
4."It increases the level of self-care in the client." - ✔✔"It uses negative reinforcement."
Rationale:Operant conditioning entails rewarding a client for desired behaviors and is
the basis for behavior modification. It uses a positive reinforcement approach. Positive
reinforcement, increased social behaviors, and increased level of self-care are accurate
characteristics of this form of therapy.
✔✔The nurse is planning relapse prevention information for a client diagnosed with
schizophrenia. The nurse understands that it is important to ensure which primary
intervention?
1.Including the client's support system in the teaching
2.Facilitating weekly maintenance therapy for the client
3.Having the client restate discharge goals and strategies
4.Stressing the importance of client compliance with the medication plan - ✔✔Including
the client's support system in the teaching
Rationale:Of the options provided, including the client's support system in the teaching
has the greatest effect on relapse prevention management because it will provide the
client with valuable support. Although the remaining options are helpful, they all focus
on the client's having the resources and abilities to be self-managing and self-reflective.
✔✔A client with a diagnosis of 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." Which
response by the nurse demonstrates therapeutic communication?
1."You have everything to live for."
2."Why do you see yourself as a failure?"
3."Feeling like this is all part of being depressed."
4."You've been feeling like a failure for a while?" - ✔✔"You've been feeling like a failure
for a while?"
Rationale: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. The
remaining options block communication because they minimize the client's experience
and do not facilitate exploration of the client's expressed feelings. In addition, use of the
word why is nontherapeutic because clients frequently interpret why questions as
accusations. Why questions can cause resentment, insecurity and mistrust.
✔✔A client is admitted to the mental health unit after an attempted suicide by hanging.
The nurse can best ensure client safety by which action?
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 to the client a staff member who will remain with the client at all times.
4.Admitting the client to a seclusion room where all potentially dangerous articles are
removed. - ✔✔Assigning to the client a staff member who will remain with the client at
all times
Rationale:Hanging is a serious suicide attempt. The plan of care must reflect action that
ensures the client's safety. Constant observation status (one-to-one) with a staff
member is the best choice. Placing the client in a hospital gown and requesting that a
peer remain with the client would not ensure a safe environment. Seclusion should not
be the initial intervention, and the least restrictive measure should be used.
✔✔The nurse is caring for a client who is at risk for suicide. What is the priority nursing
action for this client?
1.Provide authority, action, and participation.
2.Display an attitude of detachment, confrontation, and efficiency. 3.Demonstrate
confidence in the client's ability to deal with stressors. 4.Provide hope and reassurance
that the problems will resolve themselves. - ✔✔Provide authority, action, and
participation.
Rationale:A crisis is an acute, time-limited state of disequilibrium resulting from
situational, developmental, or societal sources of stress. A person in this state is
temporarily unable to cope with or adapt to the stressor by using previous coping
mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the
client (authority) who is not in control and devises a plan (action) to secure and maintain
the client's safety. When this has occurred, the nurse works collaboratively with the
client (participates) in developing new coping and problem-solving strategies.
✔✔The nurse visits a client at home. The client states, "I haven't slept at all the last
couple of nights." Which response by the nurse demonstrates therapeutic
communication?
1."I see."
2."Really?"
3."You're having difficulty sleeping?"
4."Sometimes I have trouble sleeping too." - ✔✔"You're having difficulty sleeping?"
Rationale:The correct option uses the therapeutic communication technique of
restatement. Although restatement is a technique that has a prompting component to it,
it repeats the client's major theme, which assists the nurse to obtain a more specific
perception of the problem from the client. The remaining options are not therapeutic
responses since none encourages the client to expand on the problem. Offering
personal experiences moves the focus away from the client and onto the nurse.
✔✔On review of the client's record, the nurse notes that the admission was voluntary.
Based on this information, the nurse plans care anticipating which client behavior?
AND ANSWERS SURE A+
✔✔Which statement by the nurse indicates a need for further teaching concerning
family violence?
1."Abusers use fear and intimidation."
2."Abusers usually have poor self-esteem."
3."Abusers often are jealous or self-centered."
4."Abusers are more often from low-income families." - ✔✔"Abusers are more often
from low-income families."
Rationale:Personal characteristics of abusers include low self-esteem, immaturity,
dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the
point at which their victims will do anything just to avoid further abuse. The statement
that abuse occurs more often in lower socioeconomic groups is incorrect.
✔✔A nursing student is assisting with the care of a client with a chronic mental illness.
The nurse informs the student that a behavior modification approach (operant
conditioning) will be used in treatment for the client. Which statement by the student
indicates a need for further information about the therapy?
1."It uses positive reinforcement."
,2."It uses negative reinforcement."
3."It increases social behaviors in the client."
4."It increases the level of self-care in the client." - ✔✔"It uses negative reinforcement."
Rationale:Operant conditioning entails rewarding a client for desired behaviors and is
the basis for behavior modification. It uses a positive reinforcement approach. Positive
reinforcement, increased social behaviors, and increased level of self-care are accurate
characteristics of this form of therapy.
✔✔The nurse is planning relapse prevention information for a client diagnosed with
schizophrenia. The nurse understands that it is important to ensure which primary
intervention?
1.Including the client's support system in the teaching
2.Facilitating weekly maintenance therapy for the client
3.Having the client restate discharge goals and strategies
4.Stressing the importance of client compliance with the medication plan - ✔✔Including
the client's support system in the teaching
Rationale:Of the options provided, including the client's support system in the teaching
has the greatest effect on relapse prevention management because it will provide the
client with valuable support. Although the remaining options are helpful, they all focus
on the client's having the resources and abilities to be self-managing and self-reflective.
✔✔A client with a diagnosis of 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." Which
response by the nurse demonstrates therapeutic communication?
1."You have everything to live for."
2."Why do you see yourself as a failure?"
3."Feeling like this is all part of being depressed."
4."You've been feeling like a failure for a while?" - ✔✔"You've been feeling like a failure
for a while?"
Rationale: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. The
remaining options block communication because they minimize the client's experience
and do not facilitate exploration of the client's expressed feelings. In addition, use of the
word why is nontherapeutic because clients frequently interpret why questions as
accusations. Why questions can cause resentment, insecurity and mistrust.
✔✔A client is admitted to the mental health unit after an attempted suicide by hanging.
The nurse can best ensure client safety by which action?
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 to the client a staff member who will remain with the client at all times.
4.Admitting the client to a seclusion room where all potentially dangerous articles are
removed. - ✔✔Assigning to the client a staff member who will remain with the client at
all times
Rationale:Hanging is a serious suicide attempt. The plan of care must reflect action that
ensures the client's safety. Constant observation status (one-to-one) with a staff
member is the best choice. Placing the client in a hospital gown and requesting that a
peer remain with the client would not ensure a safe environment. Seclusion should not
be the initial intervention, and the least restrictive measure should be used.
✔✔The nurse is caring for a client who is at risk for suicide. What is the priority nursing
action for this client?
1.Provide authority, action, and participation.
2.Display an attitude of detachment, confrontation, and efficiency. 3.Demonstrate
confidence in the client's ability to deal with stressors. 4.Provide hope and reassurance
that the problems will resolve themselves. - ✔✔Provide authority, action, and
participation.
Rationale:A crisis is an acute, time-limited state of disequilibrium resulting from
situational, developmental, or societal sources of stress. A person in this state is
temporarily unable to cope with or adapt to the stressor by using previous coping
mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the
client (authority) who is not in control and devises a plan (action) to secure and maintain
the client's safety. When this has occurred, the nurse works collaboratively with the
client (participates) in developing new coping and problem-solving strategies.
✔✔The nurse visits a client at home. The client states, "I haven't slept at all the last
couple of nights." Which response by the nurse demonstrates therapeutic
communication?
1."I see."
2."Really?"
3."You're having difficulty sleeping?"
4."Sometimes I have trouble sleeping too." - ✔✔"You're having difficulty sleeping?"
Rationale:The correct option uses the therapeutic communication technique of
restatement. Although restatement is a technique that has a prompting component to it,
it repeats the client's major theme, which assists the nurse to obtain a more specific
perception of the problem from the client. The remaining options are not therapeutic
responses since none encourages the client to expand on the problem. Offering
personal experiences moves the focus away from the client and onto the nurse.
✔✔On review of the client's record, the nurse notes that the admission was voluntary.
Based on this information, the nurse plans care anticipating which client behavior?
