QUESTIONS WITH SOLUTIONS GRADED A+
◉ A mental health worker is caring for a client with escalating
aggressive behavior. Which action by the MHW warrant immediate
intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loud voice to talk to the client.
D. Remains at a distance of 4 feet from the client. Answer: A. Is
attempting to physically restrain the patient.
◉ A client is admitted to the mental health unit and reports taking extra
antianxiety medication because, "I'm so stressed out. I just want to go to
sleep." The RN should plan one-on-one observation of the client based
on which statement?
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore.". Answer: D. "I don't
want to walk. Nothing matters anymore."
,◉ The RN is performing intake interviews at a psychiatric clinic. A
female client with a known history of drug abuse reports that she had a
heart attack four years ago. Useof which substance places the client at
highest risk for myocardial infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana. Answer: C. Methamphetamine
◉ A male client comes to the emergency center because he has an
erection that will not resolve. The client reports that he is taking
trazodone (Desyrel) for insomnia. Which information is most important
for the nurse ask the client?
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure? Answer: B.
Have you taken any medications for erectile dysfunction?
◉ A female client admitted to the mental health unit starts to shout and
scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distract her by offering her finger foods.
,D. Ignore the client's acting out behavior. Answer: A. Stay quietly with
the patient
◉ When developing a plan of care for a client admitted to the
psychiatric unit following aspiration of a caustic material related to a
suicide attempt, which nursing problem has the highest priority?
A. Impaired comfort.
B. Risk for injury.
C. Ineffective breathing pattern.
D. Ineffective coping. Answer: C. Ineffective breathing pattern.
◉ A female client on a psychiatric unit is sweating profusely while she
vigorously does push-ups and then runs the length of the corridor several
times before crashing into furniture in the sitting room. Picking herself
up, she begins to toss chairs aside, looking for a red one to sit in. When
another client objects to the disturbance, the client shouts, "I am the boss
here. I do what I want." Which nursing problem best supports these
observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity. Answer: B. Risk
for other related violence related to disruptive behavior.
, ◉ A RN is preparing the physical environment to interview a new client
for admission to the mental health unit. Which environmental setting
facilitates the best outcome of the interview?
A. Dim the lights in the room to help the patient feel calm.
B. Sit within two feet of the client to enhance level of safety and
security.
C. Reduce the noise level in the room by turning off the television and
radio.
D. Position table between the client and the RN for extra personal space.
Answer: C. Reduce the noise level in the room by turning off the
television and radio.
◉ The RN is providing education about strategies for a safety plan for a
female client who is a victim of intimate partner violence. Which
strategies should be included in the safety plan? (Select all that apply)
A. Purchase a gun to use for protection.
B. Establish a code with family and friends to signify violence.
C. Take a self-defense course that retaliates the abuser with injury.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
Answer: B. Establish a code with family and friends to signify violence.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.