1 A client is fearful of driving and enters a behavioral therapy program aimed at
helping him overcome his anxiety. Using systematic desensitization, he
... [Show More] is able to
drive down a familiar street without experiencing a panic attack. The nurse
recognizes that to continue positive results, the client must participate in which of the
following?
Biofeedback
Frequent practice
Positive reinforcement
Therapist modeling
2 When assessing the appropriateness of physical restraint for use with a client, a nurse
must be aware of which of the following?
Restraints may be used for client safety when staffing is inadequate.
Judicious use of restraints can enhance client care.
The least restrictive means of restraint should be chosen.
Restraints decrease the incidence of falls and injuries.
3 A nurse is working with clients in an acute care mental health facility. When
planning client care, the nurse should recognize that which of the following are
correct uses of seclusion and/or restraint? (Select all that apply.)
Chemical restraints should be the first choice of treatment for a client who is
out of control.
Seclusion and/or restraint should be implemented to maintain therapeutic
milieu.
In an emergency, the charge nurse may place a client in seclusion and/or
restraint.
A client may request to be placed in seclusion.
Seclusion and/or restraint may be used as a behavior modification technique.
4 A client has a history of using crack cocaine. The nurse should monitor for which ofthe following potential signs of drug withdrawal?
Client is drowsy most of the time.
Client speaks rapidly and talks constantly.
Client has tremors of the hands and eyelids.
Client mistakes the ceiling tiles for a jail cell.
5 A priority intervention to strengthen coping skills and to foster peer interaction for
clients with borderline personality disorder is to
set firm limits.
promote change.
remain friendly.
teach journaling.
6 Which of the following statements by a client who has been abused indicates
understanding of the need for a safety plan?
"I should hide extra money, car keys, clothes, and copies of important
documents inside my house."
"I will feel safe as soon as I have a protective order in place."
"I will let my neighbor know when I'm in trouble."
"I need to identify a particular sign that tells me and my kids that it is time to
leave."
7 A nurse is caring for a client who is taking risperidone (Risperdal). The nurse should
recognize that an increase in which of the following indicates a potential adverse
reaction to the medication?
Blood glucose
White blood cell count
Platelet count
Serum potassium8 A client presents to the emergency department following ingestion of an unknown
quantity of alcohol and lorazepam (Ativan). In planning care for this client, which of
the following requires immediate nursing action?
Blood pressure 78/56 mm Hg
Respiratory rate 8/min
Temperature 38.6°C (101.4°F)
Pulse 102/min
9 A client diagnosed with antisocial personality disorder begs a nurse to not report a
missed curfew hour. The nurse should recognize this behavior as which of the
following?
A grandiose sense of self-importance
An attempt to avoid consequences
An effort to get the nurse in trouble
A desire to gain sympathy
10 When a nurse is communicating with a client in the manic phase of bipolar disorder,
she should help the client evaluate reality by
encouraging details of client ideas and statements.
remaining neutral and avoiding power struggles.
giving in-depth explanations of nursing expectations.
allowing the client to set self-limits of behavior.
11 A nurse working on a medical-surgical unit is receiving several new admissions from
the emergency department. Which of the following clients should receive priority if
only one private room is available?
A client experiencing a panic attack and pacing the floor
A client who is depressed and who is tearful and sobbing in her pillow
A client who is angry and experiencing command hallucinationsA client who is bipolar and is in a hypomanic state
12 A nurse is caring for a client with delirium. Which of the following assessment
findings requires immediate intervention by the nurse?
Decreased level of consciousness
Increased confusion at night
Sluggish motor activity
Inappropriate speech patterns
13 A nurse is performing an assessment on a client who has expressed suicidal intent
due to the recent death of her daughter. The client is distraught and confused. Which
of the following nursing interventions takes priority?
Arrange for one-to-one observation.
Instruct the client to take slow, deep breaths.
Ask the client to sign a no-suicide contract.
Offer opportunity to talk with a spiritual advisor.
14 A nurse is about to interview an adolescent client who has been involved in sexually
risky behavior to support her drug habit. For interaction between the client and the
nurse to be therapeutic, the nurse must
have self-awareness of potential preconceived ideas.
convey a message of hope for the future to the client.
ask what is happening to make the client act in such a manner.
set firm ground rules for each counseling session.
15 During an examination in the emergency department, a nurse notes multiple bruiseson the shoulders and back of an older adult client. Which of the following should be
the nurse's priority action?
Notify the primary care provider.
Ask the client how he sustained the injuries.
Arrange for case management referral.
Inquire about the client's living arrangements. [Show Less]