The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of
sexual abuse. The charge nurse
... [Show More] learns that the nurse was sexually abused as a child. The charge nurse takes which
action when making assignments?
1
.
Organize the nurse’s assignments to include clients who have been sexually abused to promote a therapeutic
environment.
2
.
Create the nurse’s assignments as is normally done and request that the nurse begin outpatient counseling.
3
.
Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact
therapeutically.
4
.
Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of
sexual abuse.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the
initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is
important for the nurse to evaluate?
1. The client’s use of language.
2. The client’s insight into the depression.
3. The client’s socialization history and skills.
4. The client’s attitude toward medications.
An older adult client diagnosed with alcoholism receives chlordiazepoxide for 2 days for symptom management.
The client says to the nurse, “Get those bugs off of me! ” Which action does the nurse take?
1. Stop the chlordiazepoxide.
2. Assess the client for tachycardia and tremors.
3. Document an allergy to chlordiazepoxide in the client's health record.
4. Notify the health care provider that the client is experiencing
delirium.
The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client
is experiencing a panic attack?
1. Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations.
2. Decreased blood pressure, chest pain, choking feeling.
3. Increased blood pressure, bradycardia, shortness of breath.
4. Increased respiratory rate, increased perceptual field, increased concentration ability.
The nurse interacts with a client verbalizing a cocaine craving. The nurse acknowledges the client’s discomfort.
Which is the best activity for the nurse to suggest to the client?
nursing
1. Rest quietly alone in the client's room.
2. Do a crossword puzzle.
3. Say prayers for strength.
4. Walk laps around the activity area with another client.
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and
frustration. Which statement is best for the nurse to make to the parents at this time?
1. "You should focus on your baby’s personality, not appearance."
2. "Let me show you pictures of some babies before and after surgery."
3. "There are other problems with this condition that go beyond surgical correction."
4. "Has anyone else in either of your families had cleft lip or palate?"
The nurse receives hand-off communication from the unlicensed assistive personnel (UAP), who has been providing
care to clients in the home. Which situation requires intervention by the nurse?
1. A Mexican American female client who prefers not to bathe during menstruation.
2. A Hindu family places a terminally ill client on the floor after the bed bath.
3. An African American female client whose hair is shampooed every day.
4. A Pakistani male client on bedrest kneels on the floor several times during the day.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, "Became
angry and physically abusive." Which action does the nurse take first?
1. Encourage the client to verbalize feelings.
2. Assess the client for physical trauma.
3. Provide a list of shelters appropriate for the situation.
4. Assist the client to identify a support system.
The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which
observation does the nurse record before beginning a behavior modification plan for the aggressive impulses?
1. The client tells each nurse that she is his favorite nurse.
2. The client is flirtatious with female members of the staff.
3. The client threatened to hit two other clients within 2 hours.
4. The client appears insincere and superficial in his interactions.
The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks
the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take
first?
1. Ride the elevator with the client.
2. Encourage the client to get into the elevator.
3. Allow the client to avoid the elevator.
4. Encourage the client to discuss the fear.
The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for
the nurse to take which action?
1. Give the client a brief orientation to the unit.
2. Explain the activities available to the client.
3. Introduce the client to the nursing staff.
4. Ask the client to choose activities in which to participate. [Show Less]