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
13. A nurse is caring for a client who gave birth to a stillborn fetus one week ago.
She states to the nurse,”I am so angry that my doctor didn’t take better care of
me and my baby.” Which of the following responses should the nurse make?
Answer: It is important to share what you are feeling, even if it is anger
14. A nurse is contributing to the plan of care for a client who has borderline
personality disorder and exhibits manipulative behaviors. Which of the following
interventions should the nurse include in the plan to address limit setting?
Answer: Establish and explain consequences for the client’s behavior
15. A nurse is caring for an adult client who has visible injuries as a result of
intimate partner violence. Which of the following actions should the nurse take?
Answer: Encourage the client to develop a safety plan
16. A nurse in an urgent care clinic is collecting data from a client whose friend
reports a suspicion of cocaine use. The nurse should identify that which of the
following manifestations is an indicator of the client’s use of this substance?