Update 2025-2026
A nurse is assessing a family's dynamics during a counseling session. The nurse should
recognize which of the following findings as an indication of a boundary issue? - AnswersOlder
children who are responsible for their younger siblings.
A nurse is performing an admission on a client and notices that the client appears withdrawn
and fearful. to establish a trusting nurse-client relationship, which of the following actions
should the nurse take first? - AnswersInform the client that this admission is confidential.
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client
whose family reports episodes of confusion. Which of the following assessment findings
supports the nurse's suspicion of delirium? - AnswersEasily distracted.
A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client's plan of care? - AnswersPermit the client to
perform daily rituals to decrease anxiety.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which
of the following interventions should the nurse include in the plan of care? - AnswersOffer the
client high-calorie finger foods frequently.
A nurse is teaching the partner of a client who has bipolar disorder how to identify
manifestations of acute mania. Which of the following findings should the client's partner report
to the provider? - AnswersInability to sleep.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take? - AnswersAssist the client with deep-breathing exercises.
A nurse is talking with a group of parents who have recently experienced the death of a child.
Which of the following actions should the nurse take? - AnswersSuggest forming a weekly
support group for parents who have experienced the death of a child.
A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints.
Which of the following information should the nurse include in the teaching? - AnswersApply
restraints when other means of managing the client's behavior have failed.
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following
manifestations should the nurse expect? - AnswersRhinorrhea
A nurse is facilitating a community meeting for acute care clients. On client is constantly talking
and using the majority of the group's time. Which of the following interventions should the nurse
implement? - AnswersAsk the group members to discuss their feelings about this client's
monopolizing behavior.
, A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the
following findings? - AnswersTooth erosion
A nurse in a community health center is working with a group of clients who have post-
traumatic stress disorder. Which of the following interventions should the nurse include to
reduce anxiety among the group members? - AnswersGuided imagery
A nurse is preparing to discharge to home an older adult client who attempted suicide. This
client lives alone and has difficulty performing ADLs. Which of the following referrals should the
nurse initiate? (Select all that apply) - AnswersOccupational Therapy
Meal delivery services
Physical therapy
Home health services
A nurse at the provider's office is interviewing an older adult client. Which of the following
actions should the nurse plan to take? (Click on Exhibit) - AnswersUse a screening tool to
evaluate the client for depression.
A nurse is planning care for a client who has made repeated physical threats toward other on
the unit. Although the client does not want to leave the unit, the nurse requests the provider to
transfer the client to a unit that is equipped to manage violent behavior. which of the following
ethical principles should the nurse apply in this situation? - AnswersNonmaleficence
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar
disorder. Which of the following behaviors is the priority for the nurse to report to the treatment
team? - AnswersGiving away possessions.
A nurse is assessing a client for risk factors for the development of depression. the nurse
should identify that which of the following factors places the client at an increased risk for
depression? - AnswersThe client has COPD
A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative
use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at
myself." Which of the follow therapeutic responses demonstrates the nurse's use of
summarizing? - Answers"You're saying that you think you re fat and are using laxatives because
you are afraid of gaining weight."
A nurse is caring for four clients in an emergency department. The nurse should identify that
which of the following clients can give informed consent? - AnswersA 35 year old client who has
major depressive disorder.
A nurse in a community health center is teaching families of clients who have post-traumatic
stress disorder (PTSD) about expected clinical manifestations. Which of the following