1. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse
asks one of the members what kinds of things she would like to do with the group. The older
woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best
response for the nurse to make?
A "Yes, I am the leader today. Would you like to be the leader tomorrow?"
B "Yes, I will be leading this group. What would you like to accomplish during this time?"
C "Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks."
D "Yes, I am the leader. You seem angry about not being the leader yourself." - Answer --B
Over a period of several weeks, one male participant of a socialization group at a community
day care center for the elderly monopolizes most of the group's time and interrupts others when
they are talking. What is the best action for the nurse to take in this situation?
A Talk to the client outside the group about his behavior during group meetings.
B Remind the client to allow others in the group a chance to talk.
C Allow the group to handle the problem. Correct
D Ask the client to join another group. - Answer --C
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the
extended care facility and asks the nurse, "Where should I stand for the parade?" Which
response is best for the nurse to provide?
A "Anywhere you want to stand as long as you do not get hurt by those in the parade."
B "You are confused because of all the activity in the hall. There is no parade."
C "Let's go back to the activity room and see what is going on in there."
D "Remember I told you that this is a nursing home and I am your nurse." - Answer --C.
,Physical examination of a 6-year-old reveals several bite marks in various locations on his body.
X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child
is always having accidents. Which initial response by the nurse is most appropriate?
A "I need to inform the healthcare provider about your child's tendency to be accident prone."
B "Tell me more specifically about your child's accidents."
C "I must report these injuries to the authorities because they do not seem accidental."
D "Boys this age always seem to require more supervision and can be quite accident prone." -
Answer --B
A child is brought to the emergency room with a broken arm. Because of other injuries, the
nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an
injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you
touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The
mother is
A regressing to an earlier behavior pattern.
B sublimating her anger.
C projecting her feelings onto the nurse.
D suppressing her fear. - Answer --C
.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her
tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me
with that food." Which response would be most appropriate for the nurse to make?
A "I'll leave your tray here. I am available if you need anything else."
B "You're not being poisoned. Why do you think someone is trying to poison you?"
C "No one on this unit has ever died from poisoning. You're safe here."
D "I will talk to your healthcare provider about the possibility of changing your diet." - Answer --A.
, A 25-year-old female client has been particularly restless and the nurse finds her trying to leave
the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret
police are after me." Which response is best for the nurse to make?
A "No one is after you, you're safe here."
B "You'll feel better after you have rested."
C "I know you must feel lonely and frightened."
"Come with me to your room and I will sit with you." - Answer --D.
. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but
now he knows he is not. Which response is best for the nurse to make?
A "Did you really believe you were Jesus Christ?"
B "I think you're getting well."
C "Others have had similar thoughts when under stress."
"Why did you think you were Jesus Christ?" - Answer --c
. A nurse working in the emergency room of a children's hospital admits a child whose injuries
could have resulted from abuse. Which statement most accurately describes the nurse's
responsibility in cases of suspected child abuse?
A The nurse should obtain objective data such as x-rays before reporting suspicions to the
authorities.
B The nurse should confirm any suspicions of child abuse with the healthcare provider before
reporting to the authorities.
C The nurse should report any case of suspected child abuse to the nurse in charge.
D The nurse should note in the client's record any suspicions of child abuse so that a history of
such suspicions can be tracked. - Answer --C
. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea,
vomiting, and drowsiness. What action should the nurse take?
A Notify the healthcare provider immediately and prepare for administration of an antidote.