1.A nurse educator is presenting information about the nursing
process to a class ofnursing students. What definition of the nursing
process should be
... [Show More] included in the presentation?
1.Procedures used to implement client care
2.Sequence of steps used to meet the client’s needs
3.Activities employed to identify a client’s problem
4.Mechanisms applied to determine nursing goals for the client
2.A nurse on the medical-surgical unit tells other staff members, “That
client can just wait for the lorazepam; I get so annoyed when people drink
too much.” What does this nurse’scomment reflect?
1.Demonstration of a personal bias
2.Problem solving based on assessment
3.Development of client acuity to set priorities
4.Consideration of the complexity of client care
3.A teenager begins to cry when talking with the nurse about the
problem of not beingable to make friends. What is the most
therapeutic nursing intervention? TC
1.Sitting quietly with the client
2.Telling the client that crying is not helpful
3.Suggesting that the client play a board game
4.Recommending how the client can change this situation
4.After being medicated for anxiety, a client says to a nurse, “I guess you
are too busy tostay with me.” How should the nurse respond? TC
1. “I’m so sorry, but I have to see other clients”
2. “I have to go now, but I will come back in 10 minutes” ( offering self)
3. “You’ll be able to rest after the medicine starts working”
4. “You’ll feel better after I’ve made you more comfortable”
5.A physician is admitted to the psychiatric unit of a community hospital. The
client, who was restless, loud, aggressive, and resistive during the admission
procedure, states, “I will take my own blood pressure.” What is the nurse’s most
therapeutic response? TC
1.“Right now you are just another client”
2.“If you would rather, I’m sure you will do it correctly”
3.“I will get the attendants to assist me if you do not cooperate”
4.“I am sorry, but I cannot allow that because I must take your blood
pressure”(boundaries
6.What is the most important tool a nurse brings to the therapeutic nurse client relationship?
1.Oneself and a desire to help
2.Knowledge of psychopathology
3.Advanced communication skills
4.Years of experience in psychiatric nursing
9. A 6-year-old child is diagnosed with type 1 diabetes. Considering the
child’s cognitivedevelopmental level, which explanation of the illness is
most appropriate? TC
1.“Diabetes is caused by not having any insulin in your body”
2.“Diabetes will require you to take insulin shots for the rest of your life”
3.“You will be taught how to give yourself insulin now that you have diabetes”
4.“Taking insulin for your diabetes is like getting new batteries for your
superhero toys”
10. “But you don’t understand” is a common statement associated with
adolescents. What is thenurse’s best response when hearing this? TC
1.“I don’t understand what you mean”
2.“I do understand; I was a teenager once too”
3.“It would be helpful to understand; let’s talk” (paraphrasing,
offering self)4. “It’s you who should try to understand others”
11. After a therapy session with a health care provider in the mental health
clinic, a client tellsthe nurse that the therapist is uncaring and impersonal. What
is the nurse’s best response? TC
1. “Your therapist is really very good”
2. “I hope that the rest of the staff is caring”
3. “The therapist is there to help you; try to cooperate”
4. “You have strong feelings about your therapy session and your therapist(
f)eelings
13. What is the priority nursing objective of the therapeutic psychiatric
environment for aconfused client?
1.Assist the client to relate to others
2.Make the hospital atmosphere more home-like
3.Help the client become accepted in a controlled setting
4.Maintain the highest level of safe, independent functioning (safety and
autonomy)
15. A graduate nurse is preparing to apply to the State Board of Nursing for
licensure to practice as a registered professional nurse. What group primarily is
protected under the regulations of thepractice of nursing?
1.The public
2.Practicing nurses
3.The employing agency
4.People with health problems
17. A health care provider orders “Restraints prn” for a client who has a
history of violentbehavior. What is the nurse’s responsibility concerning
this order?
1.Ask that the order indicate the type of restraint
2.Recognize that prn orders for restraints are unacceptable
3.Implement the restraint order when the client begins to act out
4.Ensure that the entire staff is aware of the order for the restraint
18. A client on the psychiatric unit is undergoing a pretreatment evaluation for
electroconvulsivetherapy (ECT). The nurse doubts that the client can provide
an “informed consent” because of profoundly depressed behavior. What should
be the nurse’s initial intervention?
1.Consult with the hospital’s legal staff and follow their recommendation
2.Have the client verbalize an understanding and outcomes of the
procedure
3.Ask the client to sign the consent form because the client has not been
declared incompetent
4.Suggest to the health care provider that a family member sign the consent form
for the client
19. A pregnant client in the third trimester tells the nurse, “I want to be
unconscious for thebirth.” How should the nurse respond?
1. “You are worried about too much pain”
2. “You don’t want to be awake during the birth?”(restating for clarification)
3. “I can understand that because labor is uncomfortable”
4. “I will tell your health care provider about this request”
21. How should a nurse characterize a sudden terrorist act that causes the
deaths of thousands of adults and children and effects negatively on their
families, friends, communities, and the nation?
1.Recurring
2.Situational
3.Maturational
4.Adventitious
22. Which action should a nurse implement first when initially helping clients
resolve a crisissituation?
1.Encourage socialization
2.Meet dependency needs
3.Support coping behaviors
4.Involve clients in a therapy group
23. A single, pregnant client who is attending a crisis intervention group has
decided to go through with the pregnancy and keep the baby. What is the nurse’s
primary responsibility at thistime?
1.Confirm that this really is what the client wants to do
2.Explore other problems that the client may be experiencing
3.Select a health care provider that the client can visit for prenatal care
4.Provide information about resources from which the client may receive
assistance
24. Which is the most important assessment data for a nurse to gather from the
client in crisis?
1.The client’s work habits
2.Any significant physical health data
3.A history of emotional problems in the family
4.The client’s perception of the circumstances surrounding the crisis
25. A nurse is in the working phase of a therapeutic relationship with a
depressed client who hasa history of suicide attempts. What question should
the nurse ask the client when exploring alternative coping strategies?
1.“How have you managed your problems in the past”
2.“What do you feel you have learned from this suicide attempt”
3.“How will you manage the next time your problems start piling up”
4.“Were there other things going on in your life that made you want to die”
26. A client is diagnosed with generalized anxiety disorder. For what behavior
should the nurseassess a client to determine the effectiveness of therapy?
1.Participates in activities
2.Learns how to avoid anxiety
3.Takes medication as prescribed
4.Identifies when anxiety is developing
27. A client comes to a mental health center with severe anxiety evidenced by
crying, wringingthe hands, and pacing. What should be the first nursing
intervention?
1. Stay physically close to the client ( patients with severe anxiety are very
impulsive)
2. Gently ask what is bothering the client
3. Tell the client to try to relax by sitting quietly
4. Involve the client in a nonthreatening activity
28. A client believes that doorknobs are contaminated and refuses to touch
them, except with apaper tissue. What nursing intervention is most
therapeutic for this client?
1.Initially supply the client with paper tissues to help functioning until
anxiety is reduced( initially this is the best response stopping the rituals
before medication has had some time to take effect may be harmful and
thepatient’s anxiety may be to high to learn newcoping skills)
2.Have the client scrub the doorknobs with a strong antiseptic so that
tissues are no longerneeded
3.Encourage the client to touch doorknobs by removing all available paper
tissue until learninghow to manage the situation
4.Explain to the client that the idea about doorknobs being contaminated is part
of the illness, soprecautions are not necessary
29. A nurse is developing a care plan for a client diagnosed with obsessive compulsive disorder.Which nursing intervention will most likely increase the
client’s anxiety?
1.Helping the client understand the nature of the anxiety
2.Limiting the client’s ritualistic acts to three times a day
3.Involving the client in establishing the therapeutic plan
4.Providing the client with a nonjudgmental environment
31. When the community health nurse visits a patient at home, the patient
states, “I haven’t sleptthe last couple of nights.” Which response by the nurse
illustrates a therapeutic communication response to this patient?
1.“I see.”
2.“Really?”
3.“You’re having difficulty sleeping?”(clarification technique)
4.“Sometimes, I have trouble sleeping too.”
33. A patient diagnosed with terminal cancer says to the nurse “I’m going to
die, and I wish myfamily would stop hoping for a cure! I get so angry when they
carry on like this. After all, I’m the one who’s dying.” Which response by the
nurse is therapeutic?
1.“Have you shared your feelings with your family?”
2.“I think we should talk more about your anger with your family.”
3.“You’re feeling angry that your family continues to hope for you to be
cured?”( feelingsand clarification technique)
4.“You are probably very depressed, which is understandable with such a
diagnosis.”
34. On review of the patient’s record, the nurse notes the admission was
voluntary. Based on thisinformation, the nurse anticipates which patient
behavior?
1.Fearfulness regarding treatment measures.
2.Anger and aggressiveness directed toward others.
3.An understanding of the pathology and symptoms of the diagnosis.
4.A willingness to participate in the planning of the care and treatment plan.
35. The nurse employed in a mental health clinic is greeted by a neighbor in a
local grocery store. The neighbors ask the nurse, “How is Mary doing? She is
my best friend and is seen atyour clinic every week.” Which is the MOST
APPROPRIATE nursing response?
1.“I can not discuss any patient situation with you.”
2.“If you want to know about Mary, you need t ask her yourself.”
3.“Only because you’re worried about a friend, I’ll tell you that she is improving.”
4.“Being her friend, you know she is having a difficult time and deserves her
privacy.”
36. Which statement demonstrates the BEST understanding of the nurse’s
role regardingensuring that each client’s rights are respected?
1. “Autonomy is the fundamental right of each and every client.”
2. “A patient’s rights are guaranteed by both state and federal laws.”
3. “Being respectful and concerned will ensure that I’m attentive to my patient’s
rights.”
4. “Regardless of the patient’s conditions, all nurses have the duty to respect
patient rights.” [Show Less]