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A collection of multiple-choice questions and answers related to nursing practice, specifically focusing on topics relevant to nr 213/nur 213 exam 3. The questions cover various aspects of nursing care, including mental health, family violence, and suicide prevention. The document can be a valuable resource for students preparing for their nursing exams.
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The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?
Information regarding shelters
Instructions regarding calling the police
Instructions regarding self-defense classes
Explaining the importance of leaving the violent situation 1
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?
"You need to try to be realistic. The rape did not just occur."
"It will take some time to get over these feelings about your rape."
"Tell me more about the incident that causes you to feel like the rape just occurred."
"What do you think that you can do to alleviate some of your fears about being raped again?" 3 (trash response irl though) We have an expert-written solution to this problem! A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?
The adolescent becomes angry while speaking on the telephone and slams down the receiver.
The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking. 1 A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?
"Have you talked to your family about this?"
"Everyone feels this way when they are depressed."
"You will feel better once your medication begins to work."
"You sound very upset. Are you thinking of hurting yourself?" 4 A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?
Suggesting a reduction of medication
Allowing increased "in-room" activities
Increasing the level of suicide precautions
Allowing the client off-unit privileges as needed 3 (pt who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe)
(Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive- compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions) The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?
Incessant talking and sexual innuendoes
Grandiose delusions and poor concentration
Outlandish behaviors and inappropriate dress
Nonstop physical activity and poor nutritional intake 4
(Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately) The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
Engaging in immoral acts
Always reinforcing self-approval
Observing rigid rules and regulations
Having the need always to make the right decision 3 (these pts have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety)
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?
Provide authority, action, and participation.
Display an attitude of detachment, confrontation, and efficiency.
Demonstrate confidence in the client's ability to deal with stressors.
Provide hope and reassurance that the problems will resolve themselves. 1 The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?
Disrupted appearance because of weight
Inability to feed self because of weakness
Pain because of an inflamed gastric mucosa
Nutritional imbalance because of lack of intake 4 Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide?
"Discussing suicide with a client is not harmful."
"Those clients who talk about suicide never do it."
"Depressed clients are the only persons who commit suicide."
(pt with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.) We have an expert-written solution to this problem! Which statement by the nurse indicates a need for further teaching concerning family violence?
"Abusers use fear and intimidation."
"Abusers usually have poor self-esteem."
"Abusers often are jealous or self-centered."
"Abusers are more often from low-income families." 4
(low self-esteem, immaturity, dependence, insecurity, and jealousy. e.g. the 45th President of the United States) We have an expert-written solution to this problem! Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client?
Restrict the client smoking for 12 hours.
Enforce nothing by mouth (NPO) status for 16 hours.
Limit the client's participation in unit activities for 24 hours.
Assure that an electrocardiogram is performed within 24 hours. 4 (blood tests before, NPO 6-8hr before)
Schizophrenia
Somatization disorder
Obsessive-compulsive disorder 3 The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic?
"You have said this many times before!"
"Tell me what makes you feel that you are ready."
"I need to see changes in you to believe that you are ready to go straight."
"I'm so glad to hear you talking this way. I will let your health care provider know." 2 A client diagnosed with depression shares with the outclinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern?
"Let's talk about the circumstances that caused you to lose your job."
"There are homeless shelters available for people who are experiencing this exact situation."
"Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"
"Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep." 3
The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client?
"You look lovely today."
"You're wearing a new blouse."
"Don't worry; everyone gets depressed once in a while."
"You will feel better when your medication starts to work." 2 (pt who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client should not be told not to worry, that everyone gets depressed once in a while, or that he or she will feel better because such statements are inappropriate and minimize the client's feelings)
Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation?
Playing checkers with members of the staff
Reading in a quiet, low-stimulus environment
Engaging in a card game with other clients on the unit
Attending a clay-molding class that is scheduled for today 4 We have an expert-written solution to this problem! The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply.
Assist the client in selecting foods from the food menu.
