Answers
1. If a nurse observes a client with bipolar disorder engaging in risky behavior
during a manic episode, what is the most appropriate intervention?
Encourage the client to express their feelings.
Increase the client's medication dosage immediately.
Implement safety measures to prevent harm.
Ignore the behavior to avoid confrontation.
2. In a scenario where an assistive personnel refuses to perform a task due to a
lack of understanding of the procedure, what should the nurse do next?
Reassign the task to another team member without further discussion.
Report the AP's refusal to the nursing supervisor immediately.
Document the refusal and move on to other responsibilities.
Provide education and clarification about the task.
3. If a nurse is struggling with time management and is assigned multiple
patients with complex needs, what strategy should the nurse implement to
ensure all patients receive adequate care?
Skip non-essential tasks to save time.
Create a prioritized care plan for each patient.
Ask for help only when overwhelmed.
Focus solely on the most critical patient and neglect others.
4. What is an example of a client statement that indicates transference?
, I don’t think I need any help right now.
I feel really close to you because you remind me of my ex-
boyfriend.
Can you tell me more about my treatment plan?
I appreciate your support during this time.
5. What is a common symptom of mania in a client with bipolar disorder?
Social withdrawal
Increased energy and activity levels
Depressed mood
Sleep disturbances
6. A child from a culture other than the nurse's has recently been diagnosed
with leukemia. The client's sibling is 6 years old and expressing feelings of
anger and guilt. This reaction by the sibling is very upsetting to the parents.
How should the nurse explain the sibling's behavior?
"This behavior is abnormal. I will have the physician refer you to a
psychologist."
"This behavior is just the sibling's way to get attention."
"This is a normal response. Your other child is also affected by the
diagnosis and anger and guilt are expected feelings for a 6-year-
old."
"Your other child should not be so upset. The cancer is easily treated."
7. In a scenario where an infant refuses to take medication and continues to cry,
what should the nurse do next to ensure the medication is administered
safely?
, Force the medication into the infant's mouth to ensure it is taken.
Use distraction techniques to calm the infant before attempting to
administer the medication again.
Administer the medication quickly to minimize distress.
Wait until the infant stops crying before administering the medication.
8. Why might a statement about feeling close to a nurse due to a resemblance
to a past relationship indicate transference?
It indicates the client is confused about their treatment.
It shows the client is satisfied with their care.
It means the client is developing a professional relationship with the
nurse.
It suggests the client is projecting feelings from a past relationship
onto the nurse.
9. What is a key aspect of post-circumcision care that parents should be aware
of?
Keep the area clean and dry.
Use alcohol to clean the area.
Apply ointment daily.
Avoid all contact with the area.
10. If a school-age child from a vegan household presents with symptoms of
fatigue and developmental delays, what should the nurse assess for?
Nutritional deficiencies, particularly Vitamin B12 levels.
Psychological factors affecting the child's development.
, Signs of dehydration and electrolyte imbalance.
Infectious diseases that could cause fatigue.
11. A nurse is preparing to administer a client's scheduled dose of subcutaneous
heparin. To reduce the risk of needlestick injury, the nurse should perform
which action with used needles?
Wear gloves when administering the injection.
For multiple injections, insert the needle into the bed.
Avoid recapping the needle before disposing of it.
Recap the needle immediately before leaving the room.
12. What is a common nursing intervention for a patient diagnosed with viral
pneumonia?
Administer oxygen therapy as needed.
Limit fluid intake.
Provide a high-protein diet.
Encourage the patient to engage in strenuous exercise.
13. Why is scheduling one-on-one discussion time with a client who
monopolizes a group therapy session considered an appropriate
intervention?
It ensures that the client feels ignored and learns to share.
It encourages the client to dominate the conversation further.
It prevents the client from participating in future sessions.
It allows the nurse to address the client's needs without disrupting
the group dynamics.