COMMUNITY HEALTH NURSING FINAL QUIZ|2022 REVISED

COMMUNITY HEALTH NURSING FINAL QUIZ 1. A nurse is providing psychological counseling at a community center for families whose loved ones died in a fire. After learning that both of her children perished in the fire, a mother says to the nurse, "I can't believe they are gone. How will I make it through this?" Which of the following is an appropriate response by the nurse? A. "You are feeling overwhelmed right now" B. "Don't worry. You will have plenty of help" C. "Can I call someone to be here with you?" D. "Anyone who has had a loss like this would feel that way" In this response, the nurse uses the therapeutic communication skill of restatement to encourage further expression of feelings by the client. 2. An industrial health nurse is caring for a female employee who is requesting some medication for a headache. The nurse asks if the client knows what could be causing the headache, and the client states, "I have been under a lot of stress lately." When the nurse suggests stress management techniques, the client calmly states that she intends to take her life after work that day. She further reports that she has a pistol in the car, and that she intends to kill herself in the parking lot of the plant. Which of the following actions should the nurse take first? A. Have the company's security officers search the client's car and remove the pistol B. Call emergency medical services to transport the client to a proper treatment facility C. Contact the client's family member to pick her up from work and take her for treatment D. Explore with the client the reasons she feels that she has no options except suicide Client safety is the nurse's primary concern. The client must be transported, safely, to a treatment facility as soon as possible. In addition, the nurse should not leave the client alone until the client is safely evaluated by or admitted to a proper care facility. 3. A home health nurse is doing an assessment of an older adult client's home. Which of the following findings should the nurse realize may be the greatest potential hazard? A. a walk-in shower B. a straight staircase with arm rails C. a large area rug in the living room D. a small rug in front of the kitchen sink Small rugs that are not attached to the floor are the greatest potential hazard to the client, due to risk for falling 4. A nurse is educating a community group who lives near a nuclear power plant. The nurse is providing information about safety related to radiation exposure when a client asks "Isn't there something we should have on hand in case of a nuclear disaster?" The nurse should recognize that the client is referring to which of the following? A. potassium iodide (Pima) B. potassium cyanide C. ciproflaxcin (Cipro) D. atropine (Atropine sulfate) Potassium iodide, if taken in time and at the appropriate dosage, blocks the thyroid gland's uptake of radioactive iodine and thus could reduce the risk of thyroid cancers and other diseases that might otherwise be caused by exposure to radioactive iodine that could be dispersed in a severe nuclear accident. 5. A nurse is planning to participate in a public education program related tp prevention of West Nile virus. Which of the following instructions should the nurse include in the presentation? A. eliminate sources of standing water B. make sure immunizations are up to date C. keep all pets indoors D. Spray nests with N,N-Diethyl-m-toluamide (DEET) At least once or twice a week, clients should empty water from flower pots, pet food and water dishes, birdbaths, swimming pool covers, buckets, barrels, and cans. Discarded tires and other items that could collect water should also be removed. 6. A nurse is performing a community assessment in a rural setting. The nurse is aware that the type of health care that is most likely to be absent in this setting is which of the following? A. Tertiary care B. Primary prevention C. Chronic care D. Secondary prevention Tertiary care, or specialized consultative care, is usually obtained following a referral from a primary care provider. Specialists, typically working in a center that has personnel and facilities for special procedures, such as large medical centers, provide tertiary care. This level of care is not readily available in most rural settings. 7. A nurse manager at a clinic for homeless people notes that many of the clients have a history of mental illness and also have difficulty with abuse of drugs or alcohol. Many of the clients require treatment for both mental illness and substance addiction. While compiling figures for a regulatory agency about the clients who visit the clinic, the nurse classifies these clients as having which of the following? A. Codependency B. Bipolar disorder C. Co-morbidity D. Somatization disorder Comorbidity is the presence of more than one disease or health condition in an individual at a given time. It may also be called a concomitant disorder or dual diagnoses 8. A nurse is conducting teaching for a client who has been prescribed Ciprofloxacin (Cipro) following exposure to anthrax. The nurse understands that the client needs additional teaching when the client states which of the following? A. "I will limit my intake of coffee, tea, or cola beverages" B. "I will wear a large-brim hat and long sleeves if I am out in the sun" C. "I will take the ciprofloxacin with an antacid if I get an upset stomach" D. "I will avoid taking cirpofloxacin along with dairy products" Ciprofloxacin is an antibiotic prescribed for a wide range of serious skin infections and is also effective against inhalation anthrax. Taking ciproloxacin with antacids can impair the absorption of the medication, reducing its effectiveness. 9. A nurse is educating a community group on smallpox. When discussing the possible means for the transmission of smallpox, which of the following statements by a member of the community group indicates a need for further teaching? "Smallpox can be transmitted through... A. bodily fluids, such as blood or vomit" B. contaminated objects, such as bedding and clothing" C. bites from insects, such as mosquitoes" D. inhalation of droplets, such as from coughing" Animals and insects have not been shown to be vectors for the smallpox virus 10. A nurse is caring for employees and their family members who have become ill after a company picnic. After extensive interviews and a review of the food handling practices, the nurse determines that the most likely cause of the illnesses was a poultry dish that had been allowed to cool to room temp for several hours before being served. This step in the epidemiological process is called which of the following? A. planning B. assessing C. implementing D. evaluating This step in the epidemiological process identifies the problem and provides the information necessary to plan interventions designed to prevent outbreaks of food borne illnesses 11. A nurse is responding to a community-wide request for health care providers to come to the scene of a bomb explosion. Reporting to the disaster scene coordinator, the nurse is told that as the victims are rescued they are triaged, and either transported or sent to the parking lot for a secondary assessment. The nurse is asked to assist in the secondary assessment process to do which of the following? A. evaluate effectiveness of resuscitation B. identify life-threatening injuries C. initiate treatment of airway and breathing problems D. determine the extent of additional injuries The secondary assessment begins after the primary (triage) assessment is completed and life-threatening injuries are addressed. The object is to determine the extent of the client's injuries so that the nurse can help determine the order in which a large group of clients with less critical injuries will be treated and transported 12. A nurse working in the ED is notifiedd by the county's emergency medical services that there has been a multiple casualty accident involving a truck carrying radioactive waste. The ED charge nurse should take which of the following actions first? A. designate a decontamination area to accommodate irradiated victims B. Notify the admissions office to clear as many critical care beds as possible C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area D. notify emergency medical services of the number of casualties the department can accommodate The nurses immediate priority is to clear the ED of non-urgent clients and open up as many treatment areas as possible to receive victims 13. A community health nurse should know that, in the event of a smallpox bioterrorism threat, a mass inoculation plan would first target which of the following groups? A. newborns B. mortuary workers C. immunosuppressed clients D. clients who have eczema Smallpox is an extremely contagious, disfiguring, and deadly disease caused by the variola virus. Particles containing the virus are released into the air when an infected person coughs, sneezes or talks. Particles may also spread through direct contact, which can occur through contact with contaminated bed linen and clothing. 14. A home health nurse is caring for a client who is living in a mental health group home. During one of her visits, the nurse discovers that the client has been hoarding psychotropic medications. The nurse's initial response should be to do which of the following? A. have the client transported to an acute care facility B. attempt to determine the reason for the client's hoarding behavior C. reprimand the staff that has been administering the client's medications D. demand that the client relinquish the medication immediately The client may be hoarding the medications for a variety of reasons. He may not like the side effects of the medications, or he may be planning to overdose to end his life 15. A nurse is working in a triage area. Which of the following activities is unlikely to be a responsibility of the nurse in this setting? A. fostering positive public relations for the hospital B. performing a complete and comprehensive client assessment C. preventing cross contamination of infectious clients D. educating the client and family In the triage setting, the nurse's priority is assessment and control of client flow. The triage nurse does not use time to provide education to the client or family Education is handled by the ED staff once treatment of the client begins 16. A nurse is working in the ED when several hundred clients injured in a train collision arrive at the hospital for treatment. The triage nurse should determine that which of the following clients is in need of immediate treatment? A. a client who has neck pain and was transported to the hospital on a backboard B. a client who has epigastric and left arm pain and is diaphoretic C. a client who has nasal and orbital ecchymosis and epistaxis D. a client who has abdominal pain and is 2 months pregnant The triage nurse should recognize that a report of severe epigastric and left arm pain accompanied by diaphoresis is a classic sign on MI, which is a life-threatening emergency. This client is in need of immediate treatment 17. A public health nurse is visiting an older adult client who has chronic airflow limitation disease and is a former cigarette smoker. The client's medications include ipratropium (Atrovent) and albuterol (Proventil) inhalers, and the client has just been prescribed home oxygen to use as needed. The nurse should recognize that this client's primary prevention needs include which of the following? A. periodic pulmonary function tests B. review of appropriate use of oxygen in the home C. yearly mammography exams D. annual influenza immunizations Immunizations is a classic example of primary prevention. This client should receive influenza immunizations annually 18. In the aftermath of a large earthquake, a hospital's disaster plan is put into effect. The charge nurse must assemble a list of clients that can be safely discharged home to accommodate the anticipated admission of many victims. The charge nurse knows that it is unsafe to discharge which of the following clients? A. a client who has osteomyelitis and will require 6 weeks of IV antibiotic therapy B. a client who has Crohn's disease and is 1 day pre-op for an ileostomy C. a client who has Alzheimer's disease and is awaiting placement in a long term care facility D. a client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace This client is NPO; therefore, the client will lack bowel sounds and have a distended abdomen. This client requires nasogastric suction and cannot be discharged safely to home 19. A nurse in an ED is informed that a tornado touched down in a nearby town and that mass casualties are en route to the ED. The charge nurse's initial action should be which of the following? A. follow agency policy to activate the disaster plan B. prepare the triage rooms C. obtain additional supplies D. call in off-duty staff The nurse has little information other than several clients are expected in a short period of time. The best way to deal with this situation is to follow the agency policy for activating the disaster plan (this may mean calling the nursing supervisor or the administrator on call). The disaster plan will then delineate the roll and responsibilities of all responders, ensuring that clients are treated in a safe and orderly manner by adequate numbers of caregivers 20. A public health nurse in a community recently hit by a devastating tornado is concerned about the mental health of the community members. The nurse decides that which of the limited resources the most cost effective approach is to conduct a depression screening. The goal of the nurse's secondary prevention effort should be which of the following? A. to increase the level of awareness of depression's manifestations in the community B. to decrease the incidence of depression in the community C. to prevent the development of depression in the community D. to provide treatment to clients in the community who are at risk for depression The goal of secondary prevention actions, such as depression screening, is to identify clients who have manifestations of a disease or condition so that referrals can be made for proper treatment. Early detection through secondary prevention may help to minimize the impact of the disease. 21. A school nurse is called to the scene of a large fight that just ended. The school security officers have called the police to the scene. Which of the following actions should the nurse take first? B. triage the injured students C. provide support to help staff deal with traumatic situation D. assist in the restoration of security on the grounds The nurse from a community center will likely be the first medical responder to the site; the nurse will need to begin triaging the injured clients to assist medical personnel as they arrive 22. A community health nurse should be aware that demographic modifying factors influencing healthy behaviors include which of the following? A. family health patterns B. income and educational levels C. self-esteem D. perceived health status demographics are the statistical characteristics of human populations, such as age or income. Income and educational levels are modifiable demographics that influence a client's performance of healthy behaviors 23. A nurse is teaching a sex ed class when a student informs the nurse about having sexual intercourse with a partner who might be HIV positive. The student asks the nurse what to do. Which of the following is an appropriate response by the nurse? A. "You shouldn't worry, yet. You don't even know if your partner is HIV positive." B. "Have you confirmed that your partner is HIV positive?" C. "Would you like to have an AIDS test done?" D. "Did you use protection, such as a condom?" Obtaining this information by clarification will prevent a misunderstanding and allow for the appropriate direction 24. A nurse is caring for a client who has a positive mantoux skin test following screening for tuberculosis (TB). The nurse should inform the client that the positive reaction indicated which of the following? A. the client has never been exposed to the tubercle bacillus B. the client had infectious TB at one time but it is not inactive C. the client has active TB D. further evaluation is required A positive Mantoux test indicated only that the person has been exposed to the tubercle bacillus, and further evaluation will be needed through the use of sputum cultures and chest x-rays 25. A nurse is planning a health fair for a local community. Which of the following should be the nurse's most important consideration when deciding which screening programs will benefit the population the most? A. Identify prevalent health problems in the community B. Identify health care facilities available to clients in the community C. Identify cost of the screening programs D. Identify demographics of the community Knowing the most prevalent health problems of a population will help the nurse to decide which screening programs are needed most and which to make available 26. A nurse is recommending tai chi course to an older adult client. The nurse should inform the client that tai chi may have which of the following effects in older adult clients? A. improve vital capacity and tidal volume B. improve wound healing and prevent infection C. improve balance and decrease the risk for falls D. improve cognition and short-term memory Tai chi is an ancient Chinese martial art program consisting of a series of slow, gentle, continuous movements. Older adult clients who take part in structured tai chi programs improve their balance and physical strength, which reduces the risk for falls 27. A nurse is planning a teaching session at a community center about the prevention of mortality related to suicide. The nurse plans to target the population at greatest risk. The nurse should know that which of the following groups of clients is most at risk for suicide? A. older adult clients 75-90 B. school aged children 6-12 C. adolescent clients 12-20 D. middle-aged clients 35-64 The nurse should target the older adult client, whose risk for committing suicide is about 36.1 per 100,000 clients 28. A nurse is planning a smoking cessation program aimed at women of childbearing age. The nurse should know that reducing the rate of smoking during pregnancy is an important issue because smoking during pregnancy is associated with an increased risk of which of the following? A. infant developmental delays B. maternal osteoporosis C. maternal ulcers D. infant lung cancer -smoking during pregnancy is associated with an increased risk for developmental delays, premature birth, low birth weight, SIDS, bronchitis, and pneumonia 29. A home hospice care nurse is caring for a client who is dying. A family member of the client is talking to the nurse. Which of the following statements by the family member requires clarification by the nurse? A. "Although my mother can't get around very much, at least she is alert." B. "My siblings and I have a schedule of when we are available to provide care to our mother." C. "My biggest concern is that I don't want my mother to be in any pain." D. I'm glad that professionals will be here in case my mother stops breathing." This statement will require clarification for two reasons. The first is that when a client is admitted to hospice the care turns from curative to palliative. Hospice clients do not receive major medical interventions or resuscitative measures, such as CPR, to prolong life. The nurse needs to determine if the family member understands and accepts the goals of hospice care. Secondly, hospice care is provided primarily by family and volunteers. The nurse makes frequent visits to evaluate the client and provide support to the client's primary caregivers, and home health aids may assist with the client's physical needs. However, there is not always a professional health care provider in the client's home 30. A home health nurse is providing teaching to the primary caregiver of a client who has alzhemer’s disease about respite care. Which of the following information should the nurse include in teaching? A. it refers to a community support group for family caregivers B. it requires placing the client in an assisted living facility C. it provides family members with temporary relief from care giving D. it supplies daily assistance from a home health aid Respite care services provide family caregivers with temporary relief from the tasks associated with care giving for chronically ill family members, such as adults who have Alzheimer's disease or children who have complex medical or developmental needs 31. An occupational health nurse is providing teaching to a group of clients about the risks of the work environment. Which of the following actions is the nurse performing? A. Case management B. secondary prevention C. tertiary prevention D. primary prevention 32. A community health nurse working in a refugee center is evaluating children newly arrived to the US. Assessment of a listless, 20-month-old toddler indicated the infant is in the 6th percentile for weight and the 40th percentile for height. The toddler has thin limbs, a protuberant abdomen, and dull, dry hair. This assessment should lead the nurse to suspect the child may have which of the following? A. chronic hypoxemia B. anemia C. protein deficit D. fluid overload Growth failure, thin limbs, protuberant abdomen, and dry, dull hair characterize a protein deficit 33. A home health nurse and an assistive personnel discussing the care needs of a client. Which of the following statements by the AP should concern the nurse? A. "I will change the client's PICC line dressing on my next visit." B. "Bathing the client is something that I can do without assistance." C. "I assist the client in ambulating outdoors each time I visit." D. "Next time I visit, I plan to clean up the clutter in the client's bedroom." Changing IV dressings is not within the home health aide's scope of practice. The nurse needs to investigate this statement 34. A nurse is conducting a screening class for hypertension. Which of the following should be the nurse's secondary prevention goal? A. Prevent the onset of the condition B. Identify the severity of the condition C. Identify the condition early D. Deter condition-related complications Secondary prevention measures are those that identify and treat asymptomatic people who have already developed risk factors or preclinical disease but in whom the condition is not clinically apparent. The goal of secondary prevention is early identification of the target condition 35. A triage nurse working in an ED near a large amusement park must prioritize four clients who arrived at the same time. Which of the following clients should the nurse arrange to admit first? A. an adolescent client whose right wrist is bent at an odd angle and who reports pain with movement B. an adult client who reports burning and frequency of urination and intense flank pain for 24 hr C. a child who is on a family vacation, was health this morning and now has a runny nose and a fever of 2 hr duration D. an older adult client who has arthritis of the knee and reports pain after walking at the park all day The report of acute flank pain accompanied by symptoms consistent with a UTI should alert the nurse that the client may have a UTI that involves the kidneys. This acute infection warrants priority attention. The client who is experiencing flank pain with complaints of a presenting UTI for the past 24 hours shows that the time frame is critical and the client has an increased risk for ascending infection to the kidneys which predisposes renal loss and sepsis 36. A community health nurse at a family planning clinic is devising a program targeting adolescent sexuality. The nurse takes into consideration that, according to Erikson, the major developmental task for adolescents clients is which of the following? A. adjusting to the dramatic changes in body image B. developing hypothetical reasoning skills C. establishing the capacity for an intimate love relationship D. learning to make good choices that do not put them at risk Identity vs. role confusion (12-18 years old) adolescents are preoccupied with their changing bodies and how their body appears to others. 37. A public health nurse is conducting a community assessment. Community leaders are concerned about the potential for an outbreak of a serious communicable disease with a high mortality rate, such as bird flu. The public health nurse is asked to assist in developing a community plan to take effect in the event of an epidemic. In teaching the community leaders about infectious disease, the nurse explains that a vector is which of the following? A. mode of transmission for the disease B. microorganism that causes the infection C. environment where the pathogen can survive D. client who is susceptible to the infection 38. A nurse on a bioterrorism committee is developing a brochure to increase public awareness about the threat of inhalation anthrax. The nurse should plan to include which of the following information in the brochure? A. a vaccination for inhalation anthrax is recommended to be administered to children B. clients with symptoms of inhalation anthrax will need antibiotic treatment for 60 days C. the initial symptoms of inhalation anthrax include itchy skin lesion that blisters and scabs D. clients exposed to housemates who have inhalation anthrax must receive prophylactic treatment Anthrax is an infectious disease caused by a spore-forming bacteria Bacillus anthracis. Infection in humans most often involved the skin (cutaneous anthrax), the GI tract, or the lungs (inhalation anthrax) 39. A nurse is teaching a class at a community center about how to make healthy lifestyle changes. An attendee tells the nurse, "I work long hours at work, I never have time for exercise or anything but fast food." Which of the following goals should the nurse include in the client's nursing plan of care? A. The client will improve overall health by the next visit B. The client will introducing two green vegetables into the diet by the end of the month C. increasing activity with exercise and reducing daily stress D reducing weight by 10 lb within 2 weeks The goal is simple, measurable, and realistic. It is better to set up a number of small, separate steps as goals. 40. A client who is bipolar states to the psychiatric nurse in the mental health outreach clinic, "I no longer take my medication because I like to feel manic." Which of the following is an appropriate therapeutic nursing response? A. "You may feel good now, but what about when you get depressed?" B. "What do you like about being manic?" C. "You feel better when you don't take your medication?" D. "You really should follow your providers orders if you want to be well." This response uses the therapeutic communication tool of validating or clarifying the client's feelings. The client has states a preference for being off the medication. This open-ended response acknowledges the client's statement and allows further exploration of the subject 41. A parent brings in an 18-month-old to the ER. The child has sustained a fractured left femur. Which of the following statements by the parent might make the nurse suspect child abuse? A. "My child is so active and gets into everything" B. "My child was riding a bicycle and hot the right foot caught in the spokes." C. "My child slipped out of the high chair because the strap was too loose." D. "My child climbed up on a chair and fell down." This statement does not seem reasonable because 18--month- olds are not developmentally able to be riding bikes This should make the nurse suspicious that the parent may be trying to hide something 42. A nurse should recognize that magnetic resonance imaging (MRI) procedures are generally contraindicated for clients who have a fear of which of the following? A. Closed spaced B. Dark places C. immobilization D. needles Fear of closed spaces is the condition known as claustrophobia 43. The spouse of a chronic alcoholic client says to the nurse, "I told my husband I would leave if he did not get into treatment. Now that he is here, I feel differently. What can I do to help him?" Which of the following is a therapeutic nursing response? A. "you should attend an AA meeting. The group can teach you how best to help him stay sober." B. "You have already done a great deal by getting him here. Now, it is up to him." C. "are you feeling some responsibility for his drinking?" D. "tell me more about the kind of help you feel you are able to provide at this time." The wife is the client in this question. This response will help the wife clarify what assistance she can realistically provide without sacrificing her own needs in the process. 44. A nurse is caring for a client admitted for depression 1 week ago who was started on paroxetine (Paxil) at the time of admission. The client states to the nurse, "My family would be better off without me." Which of the following is an appropriate therapeutic response by the nurse? A. "I do not feel that you really believe that." B. "Everyone feels this way when depressed." C. "You sound upset. Are you thinking of hurting yourself?" D. "You'll feel better once your medications start working." This response represents the therapeutic communication technique of showing empathy. Telling the client "you are upset" focuses on the client's feelings, which is where therapeutic communication belongs. In addition, the nurse confronts the client who believes that "my family would be better off without me" about suicidal ideation by asking the client directly where or not she has an intent of self-harm. 45. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the therapist immediately. Which of the following responses by the nurse is appropriate? A. "You are being unreasonable, and I will not call your therapist at 0300 in the morning" B. "Why do you need to see your therapist tonight?" C. "Calm down, go back to your room, and I'll try to get in touch with your therapist right away." D. "You must be very upset about something to want to see your therapist in the middle of the night." This option is an example of the nurse showing empathy. This response addresses the client's feelings and offers an opportunity for the client to clarify the situation 46. A female client is seen in the ER with ecchymosis of the trunk and face. Upon direct questioning by the nurse, the client admits to having been struck by her spouse. When offered information about shelters for battered women, the client declines stating, "I could never leave by husband because of my kids." Which of the following is an appropriate nursing response? A. "Aren't you worried about the safety of your children?" B. "Can you identify the situations that provoke your husband?" C. "I am concerned about your safety" D. "I wouldn't put up with this if I were you." In this open-ended response, the nurse simply states concern for the safety of the client. It allows the client to respond and promotes further dialogue and expression of feelings. 47. A nurse on a mental health care unit is providing care for a client diagnosed with schizophrenia. The client is experiencing delusional thinking. Which of the following defense mechanisms is the client using when making delusional statements? A. projection B. dissociation C. displacement D. regression In projection, a client attributes unacceptable emotions and qualities to others. This is the defense mechanism that is operative in delusional thinking. 48. A client with hallucinations is admitted to the psychiatric unit. In the initial phase of establishing a therapeutic nurse-client relationship, it would be appropriate for the nurse to explore which of the following? A. perception of the presenting problem B. description of hallucinations C. feelings about hospitalization D. relationship with family In the initial, orientation phase of the nurse-client relationship, the nurse should gather data from secondary sources, establish rapport with the client and assess the client's beliefs about the reason for therapy 49. A nurse is caring for a client who is scheduled for cardiac catheterization. When arriving for the procedure, the client reports walking that morning with butterflies in the stomach, a sense of restlessness, urinary frequency, and some difficulty concentrating while driving to the hospital. The admitting nurse should assess the client's anxiety level as which of the following? A. moderate B. mild C. severe D. panic AThe combination of physical symptoms and some difficulty concentrating indicates a moderate level of anxiety. This is not unusual considering the intrusive medical procedure the client is about to undergo 50. A nurse is caring for a client whose provider has prescribed fluphenazine decanoate (Prolixin) 12.5 mg IM weekly. Available is fluphenazine decanoate 50 mg per 2 mL. How many mL should the nurse plan to administer each week? A. 0.25 B. 0.5 C. 0.75 D. 1.0 Set up an equation. Yout have 50 mg per 2 mL so, 50 mg/2 mL = 12.5 mg/X mL. Solve for X. (50)(X)= (2)(12.5). (50)(X)= 25. X= 0.5 mL. 51. Which of the following is an important short term goal for a nurse to plan with a suicidal client? A. Develop more adaptive family relationships B. Sign a contract pledging not to act on suicide plans C. explore the motivating factors for suicide D. no longer verbalize thoughts or feelings as they relate to suicide Physical safety is a priority with suicidal clients. The nurse's priority short-term goal with suicidal clients is to prevent the client from carrying out the act of suicide. 52. A widow is brought to the clinic by her adult son, who found her at home crying. She said that she could no go on alone. He tells the nurse that when his father died six months earlier, and the family was amazed at his mother's fortitude during and immediately after the funeral. She did not cry or seem unduly upset. The nurse recognizes that his mother had previously death with her husband's death by using which defense mechanism? A. denial B. repression C. introjection D. sublimation Denial is a component of the grief process. This client's emotional response to her husband's death has been delayed, but she now is experiencing the depressive phase of the grief process 53. A client admitted to the hospital with abdominal pain and GI bleeding has a colonoscopy, and colon cancer is discovered. The provider comes to the client's room, tells the client the diagnosis, discusses treatment options, and leaves. Shortly after, the nurse enters the room and the client begins yelling at the nurse stating, "I have received lousy care here and no one cares about me." The nurse recognizes that the client is demonstrating the defense mechanism of A. denial B. displacement C. regression D. projection Displacement is the redirecting of thoughts, feelings, and impulses from an object that gives rise to anxiety to a safer, more acceptable one. In this case scenario, the client is redirecting the anxiety about the diagnosis to attacking the care received while hospitalized. 54. The nurse working with a depressed client notes that the client has not come to breakfast and finds the client still in bed in a nightshirt. The client tells the nurse, "I'm too sick to bother. Leave me alone and go help someone else who is worth your time." Which of the following is an appropriate response by the nurse? A. "Everyone feels that way when they first start treatment." B. "You sound very discouraged and hopeless today." C. "You'll feel so much better once you get up and into your clothes." D. "Why do yo say that you are too sick to bother?" I this therapeutic response, the nurse uses the technique of restating and clarifying to encourage further communication from the client. Remember, in communication questions, the nurse should always address the client's feelings first. 55. A nurse is caring for a college student at the campus mental health counseling center. The student comes to see the nurse after getting a low grade in a course, and spends the entire session blaming the teacher and complaining about the lack of help seminars. The nurse recognizes this behavior as an example of which of the following defense mechanisms? A. projection B. displacement C. Undoing D. Conversion Defense mechanisms are processes that serve to provide relief from emotional conflict and anxiety. Displacement is a type of defense mechanism, in which the client, operating unconsciously, takes unacceptable emotions, ideas, or wishes and transfers them from their original object to a more acceptable substitute. The client in this case scenario is experiencing an emotion or thought that he can't deal with directly (failure), so the unacceptable emotion (I failed) is transferred into blaming the teacher and course for being inept (I was unable to succeed because of the poor teaching) 56. A client is admitted to the psychiatric unit for depression. The nurse observes an improvement in the client's grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Which of the following is an appropriate therapeutic response by the nurse? A. "You must be getting better. You look great!" B. "Let's go put some make-up on and make you look even better." C. "Why did you get all dressed up today? Is it a special occasion?" D. "You look nice after your bath and shampoo." This option acknowledges and affirms the client's behavior. It provides reinforcement and is good for the client's self-esteem. 57. A client is hospitalized with schizophrenia. During a conversation with the nurse, the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which statement by the nurse would be appropriate at this time? A. "Did I say something wrong that made you feel tense?" B. "Do you often feel tense when you are talking to a health car provider?" C. "What were we discussing when you began to feel uncomfortable?" D. "I sometimes feel tense, too, when I'm talking to a stranger." This statement seeks clarification by asking for information about when the client became tense. This open-ended question is therapeutic because it encourages further communication and expression of feelings 58. A client in a long term care facility asks the nurse to telephone her husband and ask him if he remembered to pick up his suit at the cleaners. The nurse knows the client's husband died five years before. Which of the following is an appropriate nursing response? A. "How long were you married to your husband?" B. "Remember? Your husband died five years ago." C. "You've forgotten that your husband is dead, haven't you?" D. "You miss your husband a lot, dont you?" This therapeutic nursing response uses empathy to validate the client's feelings and acknowledge her experience. This is the best option because the nurse is responding to the feelings underlying the client's comment, instead of the disordered content 59. A nurse is caring for a client diagnosed with borderline personality disorder. The client becomes attached to one of the nurses and refuses to talk with any of the other staff members. The client says the other staff members are abusive and untrustworthy.The client is using which of the following defense mechanisms? A. splitting B. reaction formation C. projection D. idealization Splitting is relating to others as if they are all good or all bad, rather than as integrated individuals with both positive and negative attributes. 60. A nurse is working in a busy pediatric ER. In which of the following cases should the nurse maintain a high index of suspicion of physical child abuse? A. a 14 month old child who is reportedly "clumsy" with many bruises on bony prominence in various stages of healing B. a 8 month old who reportedly nearly drowned after climbing into the tub and turning on the water C. a 6 year old with a fracture of the tibia and fibula, which reportedly occurred while riding a bike D. a 3 year old with 15% burns in a splash pattern over the face and chest reportedly sustained when a tablecloth was pulled, spilling a teapot A 9 month old could climb into the tub, but it is unlikely that he could turn on the water. This should definitely be followed up. The reported cause of the accident seems inconsistent with the developmental abilities of most 9 month olds 61. A community health nurse is caring for a client who was exposed to the human immunodeficiency virus (HIV) 2 days ago. The client asks the nurse what she should do. Which of the following responses should the nurse make? D. “You will need to take prophylactic medications for 4 weeks. 62. A public health nurse is responsible for several activities in the local community. The nurse is implementing tertiary prevention when he takes which of the following actions? A. Advocating for the expansion of mental health rehabilitation facilities with community leaders 63. A home health nurse is prioritizing visits for four clients. Which of the following clients should the nurse plan to visit first? D. A client who has type 2 diabetes mellitus and reports a new fissure between her toes 64. A community health nurse is teaching a group of adult clients about factors that influence health behaviors. Which of the following is a modifiable risk factors that the nurse should include in the teaching? B. immunization status 65. A nurse is teaching a group of older clients about complementary and alternative therapies. Which of the following interventions should the nurse recommend to improve balance? TAI CHI