HESI Computerized Adaptive Testing (CAT) Test Bank

HESI COMPUTERIZED ADAPTIVE TEST (CAT) TEST BANKING TOPTARGET ACADEMICS [Company address] HESI Computerized Adaptive Testing (CAT) Test Bank A nurse is counseling the spouse of a client who has a history of alcohol abuse. What does the nurse explain is the main reason for drinking alcohol in people with a long history of alcohol abuse? 1 They are dependent on it. 2 They lack the motivation to stop. 3 They use it for coping. 4 They enjoy the associated socialization. Ans- 1 Alcohol causes both physical and psychological dependence; the individual needs the alcohol to function. Alcoholism is a disorder that entails physical and psychological dependence. Because alcohol is so physiologically addictive, the client's body craves the alcohol, so most clients lack the motivation to stop because they will go into withdrawal. Clients who abuse alcohol have numbed their ability to utilize other coping mechanisms, so alcohol is used as an excuse for coping. People with alcoholism usually drink alone or feel alone in a crowd; socialization is not the prime reason for their drinking. How do adolescents establish family identity during psychosocial development? Select all that apply. 1 By acting independently to make his or her own decisions 2 By evaluating his or her own health with a feeling of well-being 3 By fostering his or her own development within a balanced family structure 4 By building close peer relationships to achieve acceptance in the society 5 By achieving marked physical changes Ans- 1,3 An adolescent establishes family identity by acting independently for taking important decisions about self. They also need to foster their development along with maintaining a balanced family structure. Health identity is associated with the evaluation of one's own health with a feeling of well-being. By building close peer relationships, an adolescent develops a sense of belonging, approval, and the opportunity to learn acceptable behavior. These actions establish an adolescent's group identity. The sound and healthy growth of the adolescent, with marked physical changes, helps to build an adolescent's sexual identity. A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1 Asking the father about his relationship with his wife 2 Asking the father how he held the child when she was an infant 3.Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4 Telling the father not to be concerned and stressing that the child will outgrow this developmental phase Ans- 3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong. What is most appropriate for a nurse to say when interviewing a newly admitted depressed client whose thoughts are focused on feelings of worthlessness and failure? 1 "Tell me how you feel about yourself." 2 "Tell me what has been bothering you." 3 "Why do you feel so bad about yourself?" 4 "What can we do to help you while you're here?" Ans- 1 Because major depression is a result of the client's feelings of self-rejection, it is important for the nurse to have the client initially identify these feelings before developing a plan of care. Later discussion should be focused on other topics to prevent reinforcement of negative thoughts and feelings. "Tell me what has been bothering you" is asking the client to draw a conclusion; the client may be unable to do so at this time. Also, depression may be related not to external events but instead to a client's psychobiology. Asking why does not let a client explore feelings; it usually elicits an "I don't know" response. "What can we do to help you while you're here?" is beyond the scope of the client's abilities at this time. A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? 1 "I don't feel too good today." 2."I feel much better; today is a lovely day." 3 "I feel a little better, but it probably won't last." 4 "I'm really tired today, so I'll take things a little slower." Ans- 2 A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't last"; and "I'm really tired today, so I'll take things a little slower" are all typical of the depressed client; none of these statements signals a change in mood. During a group discussion it is learned that a group member hid suicidal urges and committed suicide several days ago. What should the nurse leading the group be prepared to manage? 1 Guilt of the co-leaders for failing to anticipate and prevent the suicide 2 Guilt of group members because they could not prevent another's suicide 3 Lack of concern over the suicide expressed by several of the members in the group 4.Fear by some members that their own suicidal urges may go unnoticed and that they may go unprotected Ans- 4 Ambivalence about life and death, plus the introspection commonly found in clients with emotional problems, can lead to increased anxiety and fear among the group members. These feelings must be handled within the support and supervisory systems for the staff; the group members are the primary concern. Guilt that the group's leaders or members might feel because they could not prevent another's suicide will probably be a secondary concern of the group leader. Lack of concern over the suicide expressed by several of the members in the group is not a primary concern, but this should be explored later to determine the reason for such apparent indifference, which may be a mask to cover true feelings. Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2.Radiographs of the hand and wrist 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test Ans- 2 Skeletal growth in a child can be determined from the ossification centers. At 5 to 6 months of age, the capitate and hamate bones in the wrist are the earliest centers. Therefore radiographs of the hand and wrist will help determine skeletal growth in the child. Electroencephalogram reports will help assess a child's brain activity. MRI is used to scan the internal structures of a client. The Denver Developmental Screening Test is used to understand developmental issues of a child. A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1.Changing the topic to reality-based events 2 Continuing to discuss the delusion with the client 3 Getting the client involved in a social project with peers 4 Disputing the perceptions with the use of logical thinking Ans- 1 Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Encouraging discussion will give validity to the delusion. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Challenging the client may increase anxiety. A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3.Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving Ans- 3 Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for selfdirected violence, they do not have the suicide risk of older single men with chronic health problems. Which stages would the nurse explain that a toddler goes through, according to Freud's theory? Select all that apply. 1 Oral 2 Anal 3 Phallic 4 Genital 5 Latency Ans- 1,2 According to Freud's theory, a toddler goes through the oral and anal stages. The phallic stage is seen in children between the ages of 3 to 6 years. The genital stage is seen during puberty through adulthood. The latency stage is seen in children ages 6 to 12 years of age. A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1 Inept 2 Eccentric 3 Impulsive 4 Dependent Ans- 3 Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder. An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. What initial statement by the nurse during the admission procedure would be most helpful to this client? 1 "You're a little disoriented now, but don't worry. You'll be all right in a few days." 2 "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you." 3 "I'm the nurse on duty today. You're in the hospital. Your family can stay with you for a while." 4 "Let me introduce you to the staff here first. In a little while I'll get you acquainted with our unit routine." Ans- 2 Familiarity with the environment and a self-introduction may help promote security and feelings of trust. Telling the client "You're a little disoriented now, but don't worry. You'll be all right in a few days" denies the client's feelings and provides false reassurance. A selfintroducing one's self followed by telling the client that of being in the hospital and that the family may stay for a while denies the client's feelings but does provide self- introduction and orientation regarding the client's location. A person under stress cannot assimilate much information; verbiage could lead to more confusion. Which identity may fail to develop if the adolescent fails to feel a sense of belonging and acceptance? 1 Sexual identity 2 Group identity 3 Family identity 4 Health identity Ans- 2 Failure to feel acceptance and belonging results in failure to establish a group identity. A lack of physical evidence of maturity can predispose the adolescent to fail to establish a sexual identity. Adolescents depend on these physical cues because they want assurance of maleness or femaleness and do not wish to be different from their peers. If an adolescent fails to foster independence and balance in the family structure, it may hamper family identity. Healthy adolescents evaluate their own health on the basis of feelings of wellbeing, ability to function normally, and absence of symptoms. In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting? 1 Ideas of reference 2 Loose associations 3 Delusional thinking 4 Tactile hallucinations Ans- 3 Delusions are false fixed beliefs that have a minimal basis in reality. This is a somatic delusion. Ideas of reference are false beliefs that every statement or action of others relates to the individual. Loose associations are verbalizations that sound disjointed to the listener. Tactile hallucinations are false sensory perceptions of touch without external stimuli. Which should the nurse encourage for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment? 1 Wearing make-up 2 Making up missed work 3 Participating in sports activities 4 Participating in creative activities Ans- 2 Making up missed work is an activity the nurse can encourage to enhance a sense of accomplishment for a school-age client who is diagnosed with a chronic illness. Wearing make-up is often encouraged for an adolescent client. Participation in sports activities enhances the development of peer relationship in the school-age child. Participating in creative activities allows the school-age child to learn through concrete operations. A nurse is caring for a client exhibiting compulsive behaviors. The nurse concludes that the compulsive behavior usually incorporates the use of which defense mechanism? 1 Projection 2 Regression 3 Displacement 4 Rationalization Ans- 3 Displacement is the unconscious redirection of an emotion from a threatening source to a nonthreatening source. Projection is the attribution of one's unacceptable feelings and thoughts to someone else. Regression is the return to an earlier, more comfortable level of behavior; it is a retreat from the present. Rationalization is the attempt to make unacceptable behavior or feelings acceptable by justifying the reasons for them. A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can't be cancer, because it doesn't hurt." What is the nurse's most therapeutic response? 1 "Let's hope that it isn't malignant." 2 "What do you know about breast cancer?" 3 "Most lumps in the breast are not malignant." 4 "Has your primary healthcare provider told you that it wasn't cancer?" Ans- 2 Asking what the client knows about breast cancer allows the nurse to assess the client's understanding of breast cancer and to clarify any misconceptions. Saying that they should hope that the growth isn't malignant avoids an opportunity to teach, and it is a type of false reassurance. The statement may actually increase feelings of hopelessness if the lesion is determined to be malignant. Although correct, stating that most lesions are benign provides a false sense of security and avoids an opportunity to teach. Asking whether the primary healthcare provider has told the client that it wasn't cancer focuses on what the primary healthcare provider said rather than on what the client knows and may limit further communication of feelings and beliefs. A nurse in the emergency department is assessing a client who has been physically and sexually assaulted. What is the nurse's priority during assessment? 1 The family's feelings about the attack 2 The client's feelings of social isolation 3 The client's ability