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BUNDLE: Hesi Exit Cat Exam 1, 2, 3, 4 & Final Exam TEST BANK Questions & Answers, All 100% Rated, 2024
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Hesi Exit Cat Exam 1, Answered
Hesi Exit Cat Exam 1, Answered-A client is comatose upon arrival to the emergency department after falling a roof. The client flexes with painful stimuli, ... [Show More] and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? - A nasopharyngeal tube A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? - Answer: 200 25 ml x 8hrs = 200 The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? - Check the probe position A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30-second interval followed by an apneic period. What intervention should the nurse implement? - Reassess the respiratory rate, counting for one full minute A retiree with depression complains of feeling "lonely and having no purpose" in life.Based on Erikson's developmental theory, which questions suggest that the nurse understands the client's most important emotional need? - "What about your life makes you proud?" Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the client's symptoms may indicate which condition? - A cervical laceration In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? - An elderly client with Alzheimer's disease complicated by dysphagia The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action has the highest priority when the nurse implements this prescription? - Set the flow meter 9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this nurse take first? - C. Instruct the nurse to select another injection site 10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary function? - "Chest physiotherapy should be performed at least twice a day" The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? - Encourage physical activity The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1 diabetes mellitus. The parents correctly understands signs of hypoglycemia if they include which symptom? - Sweating The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an immobile client. What documentation of this finding is best for the nurse to enter into the client's record? - Stage 1 pressure ulcer on sacrum When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper arms. The child's aunt tells the nurse that the child's parents abuse drugs and alcohol. What intervention is most essential for the nurse to implement? - Report assessment findings to the proper legal authorities 15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? - Acute withdrawal from anticonvulsant medication A Chinese-American client who just delivered a baby states that she will not be able to take the prescribed sitz baths to help heal her episiotomy incision because this will cause an unhealthy balance of cold and hot forces. When planning nursing care, what nursing diagnosis has the highest priority? [Show Less]
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Hesi Exit Cat Exam 2, Exam Questions & Answers
Hesi Exit Cat Exam 2, Exam Questions & Answers-59 yo male client is brought to the emergency room where he is assessed to have a Glasgow coma scale of 3. B... [Show More] ased on this assessment, how should the nurse characterize the clients’ condition? a. client has increase icp b. he has a good prognosis for recovery c. this client is conscious, but is not oriented to time and place d. he is in a coma and has a very poor prognosis - d. he is in a coma and has a very poor prognosis At a community health fair, 50 yo female tells the nurse that she has an annual physical exam that includes a breast exam and an annual mammogram. How should the nurse respond? a. encourage the woman to explore her fears about breast cancer b. ask the woman if she performs monthly breast self-exams c. recommend the women for adhering to the recommend cancer detection guidelines d. advise the woman that mammogram are only needed every two yrs of age - b. ask the woman if she performs monthly breast self exams Which assessment finding should indicate to the nurse that client with arterial hypertension is expericing a cardiac complication? a. complaints of occipaital headache b. palpable dorsal is pedis pulse bilaterally c. complaints of SOB on exertion d. bp of 160/90 - c. complaints of SOB on exertion a college student who is diagnosed with vaginal infection and vulva irritation describes the vaginal discharge as having cottage cheese appearance. Which prescription should the nurse implement first? a. cleanse perineum with warm soapy water 3 times per day b. instill the first dose of nystatin vaginally per applicator c. perform glucose measurement using capillary blood sample d. obtain a blood speciment for sexually transmitted disease - b. instill the first dose of nystatin vaginally per applicator a client in acute renal failure has serum potassium of 7.5. Based on this finding, the nurse should anticapate implementing which action? a. administer IV NS rapidly and NPH subq b. administer a retention enema of kayexalate c. add 40 KCL to present IV solution d. administer lidocaine bolus IV push - b. administer a retention enema of kayexalate A client who had an intraosseous (IO) cannula placed by the healthcare provider for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse takes first? a. Discontinue the IO infusion b. Administer an analgesic via the IO site c. Elevate the extremity with the IO site d. Notify the healthcare provide - a. Discontinue the IO infusion The nurse-manager of a perinatal unit is notified that one client from the Medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? a. A 45-year-old who has a chronic hepatitis B. b. A 35-year-old with lupus erythematous c. A 19-year-old who is diagnosed with rubella d. A 25-year-old with herpes lesions of the vulva - b. A 35-year-old with lupus erythematous A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Breathe into the spirometer using normal breath volumes b. Exhale forcefully into the tubing for 3 to 5 seconds c. Inspire deeply and slowly over 3 to 5 seconds d. Perform IS breathing exercises every 6 hours - c. Inspire deeply and slowly over 3 to 5 seconds The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? a. You will be able to cope with your symptoms b. It will help you function better in the community c. The medication will help you think more clearly - c. The medication will help you think more clearly A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement? a. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating c. Tell the client to skip that day's dose and resume taking the Zithromax the next day d. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast - b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? a. Avoid douching b. Treat sexual partner (s) concurrently c. Avoid using moist washcloths when bathing d. Postpone becoming pregnant until the infection is treated - b. Treat sexual partner (s) concurrently A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take? a. Tell the client to go directly to the hospital for admission to labor and delivery for active labor b. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour c. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection - b. Send the client home and instruct her to call the clinic when her contractions occur Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker? a. Wear long-sleeved clothing when outdoors b. Report the onset of sore throat c. Eat plenty of potassium-rich food d. Change the position slowly - d. Change the position slowly Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. Place a pulse oximeter on the heel b. Swaddle the infant in a warm blanket c. Record the findings on the flow sheet d. Check the vital signs in 15 minutes - c. Record the findings on the flow sheet [Show Less]
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Hesi Exit Cat Exam 3, Answered
Hesi Exit Cat Exam 3, Answered-An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives in an elated state. What... [Show More] is the best room assignment the nurse can make for this client? - A quiet room away from the nurse's station. The community mental health nurse is planning to visit four clients with schizophrenia. Which client should the nurse see first? - A mother who took her children from school because aliens were after them. A female client, the mother of two small children, appears depressed after learning from her healthcare provider that she has multiple sclerosis. Which nursing intervention should the nurse implement first? - Sit quietly with the client and answer questions she may ask. Which statement by a client with emphysema indicates the best understanding of the purpose of pulmonary function testing? - "It will measure how well my lungs are working." An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay? - Invite him to participate in the evening group activity. Which individual may legally sign an informed consent? - A 16-year-old mother for her newborn. The nurse working on a psychiatric unit is concerned about providing ethical and legally defensible care for clients on the unit. Which occurrence is an indication that a client's civil rights are being violated? - refused to take an oral psychiatric medication is administered the same medication as an IM injection. Which statement by the mother of a toddler girl indicates to the nurse that scheduled vaccine should not be administered? - "Her throat closed up so bad she couldn't breathe the last time she got this shot." Thirty-six hours after delivery, the nurse assesses a client's fundus just above the umbilicus and displaced to the right of the midline. What actions should the nurse take first? - Palpate the bladder for distention. 10. A hospitalized 81-year-old female client has numerous complaints and uses her call button often to summon staff to help her with activities that she is capable of performing for herself. Which plan might be most beneficial in dealing with this client? - Check on the client at designated time intervals and let the client know when the nurse will return. 11. When giving a cooling bath to reduce the fever of a 3-year-old child, which action should the nurse include? - Pour tepid water over the child's back and chest. The nurse determines that a client has a potential (high risk) problem. What is important for the nurse to do when planning care? - Direct nursing actions toward reducing risk factors. The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these lower immunization groups? - Designated clinics conveniently located in target neighborhoods. The first time a male client stands at the bedside following a total hip replacement, he reports severe pain in his left calf. What intervention should the nurse take first? - Return the client to bed and assess the lower extremities. A client is receiving an IV of 5% dextrose in Lactated Ringer's solution at a rate of 100 ml/hour. The client tells the nurse, "I don't need to eat because I'm getting all the nutrition I need through this IV needle." What initial response would be best for the nurse to provide this client? - "Only a very small amount of the calories you need are provided by your IV." The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment? - "The nurse at night is trying to poison me with pills." A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement? - Encourage the client to perform foot exercises regularly while his mobility is limited. 18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg indicates the best understanding of the appropriate activity level for his disorder? - "During this illness, I need to keep my leg as immobile as possible." The nurse has conducted a cancer prevention community education program. In evaluating the participant's understanding of the carcinogens, what statement indicates an accurate understanding? - Substances that change a cell so that it becomes cancerous are potential cause of cancer 20. A 25-year-old female client is diagnosed with endometriosis by her healthcare provider. Which nursing diagnosis has the highest priority? - Pain related to extrauterine tissue inflammation. The charge nurse is supervising a newly licensed practical nurse (PN) who is administering medications. The PN notes that a client with exophthalmus is scheduled to receive artificial tear drops. What action should the charge nurse implement? - Remind the PN to evaluate the effectiveness of the medication after administration. The charge nurse is assessing the morning lab work on four clients. Which client's laboratory findings should prompts the charge nurse to contact the healthcare provider immediately? - c. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L. When assessing a client with Raynaud's disease, which symptoms should the nurse expect the client to exhibit? - Coldness, pain and pallor of fingertips, toes, and tip of nose. A client is currently receiving an infusion of 25,000 units of Heparin in 500ml of normal saline at 10 ml/hour. A prescription is received to change the rate of the infusion to 700 units of Heparin per hour. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only.) - Answer: 14 An elderly client is suspected of having a cardiac dysrhythmia. The nurse knows that it is most important to obtain which information when assessing this client? - Changes in mentation, personality, and behavior. A client has developed drug toxicity after receiving a high dose of a medication with a prolonged half-life. After consulting with the health care provider, the nurse expects to administer which treatment plan? - Several dose of antagonistic medication with a short half life administered at frequent time intervals. The nurse is assigned to care for a group of clients. Based on priority of need, arrange in the order in which the nurse should assess these four clients, with the first client the nurse should assess on top and the last client the nurse should assess on the bottom. The client who has - A T6 spinal cord injury with a blood pressure of 180/98. Type 1 diabetes mellitus with a blood sugar of 55 mg/dl. End stage renal disease with a serum creatinine of 10 m. A total hip prosthesis with a 12 g hemoglobin. 28. A 22-year-old female client calls the public health clinic because her breasts are tender and she felt several small lumps during a breast self-examination (SBE). What information should the nurse elicit from the client first? - Date of last menstrual period. 29. An adolescent female who has been a lacto-ovo-vegetarian for six months tells the nurse she is experience increased fatigue. What dietary recommendation should the nurse provide? - Eat spinach three times a weeks. A client who has been admitted to the Emergency Department following a sexual assault tells the nurse that she wants to use emergency contraception. Pending the results of a pregnancy test, what information is most important for the nurse to obtain from this client? - Length of time since the rape occurred. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? - Offer information about ultrasonography and genotyping to determine sex assignment. A nurse is assessing a client who as an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. What intervention should the nurse implement? - Document the findings. What assessment finding places a client at risk for problems associated with impaired skin integrity? - Capillary refill 5 seconds. The nurse is evaluating discharge teaching of an adolescent who had a long leg cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care? - "I will put adhesive tape around the edges of the cast if they become sharp." [Show Less]
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Hesi Exit Cat Exam 4, Questions & Answers
Hesi Exit Cat Exam 4, Questions & Answers-An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she at... [Show More] tempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds - a Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia. - D When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what nursing intervention should the nurse implement? A) Determine if the client has any allergies to iodine B) Explain that the client will not be able to move her head throughout the CT scan. C) Premedicate the client to decrease pain prior to having the procedure. D) Provide an explanation of relaxation exercises prior to the procedure. - B A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A) Elevated blood pressure. B) Allergy to shell fish. C) Right hip replacement. D) History of atrial fibrillation. - C A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" What is the best response by the nurse? A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." C) "How do you feel about what the healthcare provider said?" D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." - B What is the normal range for cardiac output? - 4-8L/min A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being admitted. Why would this client not be a candidate for for thrombolytic therapy? - Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours before being brought to the medical center What are plate guards? - Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. Which condition is considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age. - D A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing intervention would the nurse implement to address this condition? A) Turn Nancy every two hours and perform active range of motion exercises. B) Place the objects Nancy needs for activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy in forming sounds to words. D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. - B A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully allows them to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed. B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed. - B A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated? A) Encourage the client to use the incentive spirometer and to cough. B) Administer oxygen by nasal cannula. C) Request a prescription for sodium bicarbonate from the health care provider. D) Inform the charge nurse that no changes in therapy are needed. - A The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A) Limit dietary selection of cholesterol to 300 mg per day B) Increase intake of soluble fiber to 10 to 25 grams per day. C) Decrease plant stanols and sterols to less than 2 grams/day. D) Ensure saturated fat is less than 30% of total caloric intake. - B A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A) Prevention of deformities. B) Avoidance of joint trauma. C) Relief of joint inflammation. D) Improvement in joint strength. - A A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A) Frequent urinary tract infections. B) Inability to get pregnant. C) Premenstrual syndrome. D) Chronic use of laxatives. - B A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis. - B [Show Less]
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Hesi Exit Cat Final Exam Test Bank, Questions & Answers (All Explained, 100% Rated)
Hesi Exit Cat Final Exam Test Bank, Questions & Answers (All Explained, 100% Rated)-A nurse is counseling the spouse of a client who has a history of alcoh... [Show More] ol 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. - 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 – 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 - 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?" - 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." - 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 - 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 - 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 - 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 - 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 self-directed 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 – 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 - 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. [Show Less]
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