COMPLETE ANSWERS
1.A nurse is collecting data from a client who is experiencing alcohol
withdrawal. Which of the manifestation should the nurse expect?
Answer: Diaphoresis
2. A nurse in a long-term care center is caring for an adult client who has
Alzheimer’s disease and whose partner died several years ago. The client
appears upset and asls the nurse when his partner will visit again. The nurse
states,”It seems like you are feeling lonely. Let’s take a walk outside and
talk.’ Which of the following communication strategies is the nurse using?
Answer: Validation therapy
3. A nurse is reinforcing teaching with a client who has schizophrenia and a
new prescription for chlorpromazine. Which of the following statements
should the nurse include in the teaching?
Answer:” The voices you have been hearing should decrease.”
4. A nurse is reinforcing teaching with a client who has generalized anxiety
disorder and is to start therapy with buspirone. Which of the following
statementsshould the nurse identify as an indication that the client
understands the information?
Answer: “I should expect some improvement of my symptoms in about
10 days
5. A nurse is caring for a client who has major depressive disorder(MDD).
The client states.”I have nothing to live for anymore. I just can’t go on.”
Which of the following responses should the nurse make?
Answer: Are you thinking about ending your life
6. A nurse at an outpatient mental health clinic is assisting with a group
therapy session. One of the participants is having difficulty staying seated
and states loudly to the therapist.”I know more than you do about the people
, in this room!” The nurse should identify that which of the following findings
is the likely explanation for the client’s behavior?
Answer: Hypomania
7. A nurse is assisting with a mental status examination for a client who has
schizophrenia. Which of the following statements should the nurse make to
gather information about the client’s ability to think abstractly?
Answer: How is an orange similar to an apple
8.A nurse is reinforcing teaching with the parent of a child who has ADHD
and is exhibiting disruptive behaviors at home. Which of the following
actions should the nurse instruct the parent to take?
Answer: Initiate a point system for the child
9. A nurse is collecting data from a client who is having difficulty coping
with the death of his child. Which of the following questions by the nurse is
the priority?
Answer: Do you think about harming yourself
10. A nurse is reinforcing teaching about thought stopping with a client who
has a phobia of riding in automobiles. Which of the following client
statements indicates an understanding of the instructions?
Answer: I will snap a rubber band on my wrist when I feel anxious
about riding in a car
11. A nurse is assisting the charge nurse with the preparation for an in-
service about negligence for a group of newly licensed nurses. Which of the
following scenarios should the charge nurse use as an example to identify
negligence?
Answer: A nurse does not notify the provider of a change in condition
for a client who has schizophrenia
12. A nurse in a provider’s office is collecting data from an older adult client
whose adult child reports that she “seems confused and can’t seem to
remember much.”Which of the following findings should lead the nurse to
suspect delirium?
Answer: The client’s level of consciousness changes during the interview