QUESTION 1
A nurse Is caring for a client wha requires seclusion to prevent harm ta others on the unit. Which of the follawing is an appropriate action for the
nurse
to take?
() Document the client's behaviar prior 1o being placed In secusion,
© Assess the client's behavior once every hour.
© Ofter fuids every
2v
@ Owcuss with the client his inappropriate behavior prior to seclusion.
QUESTION 2
—
wvacuaty first?
© ot whe v whemichisn st s consed
@ & e s i wetretten anct wears o haarg ot
Q4 et who m i datcry and recring cepgen
Al ot P 4 A et ) Taanc SUSgmn
O a¢tion
QUESTION 3
A e @ Careg for & ter =t wmergerey SuparTeTt i the plan
1100
Tumpesaturn 16.8° C (0037 1}
Vwart rate 92/
Worpirat
1590 ®
uyien satisration 67w on romm s
Mesgir atory ¢
W 140090 mm g
wyen watunation 3% on rosm s
© e s ey 2 r
@ Doncuss wath the chent b inagpropriste hehawar prioe 10 seckision
QUESTION 4
, A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement
and the nurve offers a bed pan. The client states. “I've always used the bathroom ~ Which of the following respomes should the nurse make?
QUESTION 5
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the
nurse plan to use during the group session?
) Encourage clients 10 s a tmetine for thew own grieviny
Initiate
o discu to cope with changes
in tamily dynamics.
Assis 4 have been prevented
ourage chents from sharing negative asper el celationship
with the deceased persons.
QUESTION 6
A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
a. Conduct apregnancy test
b. Requests mental health consultation for the client
c. Provide atrained advocate to stay with the client
,6. Anurse is caring for a client who has major depressive disorder. After discussing the
treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but
will not sign the consent form. Which of the following actions should the nurse take?
a. Request that the client’s partner sign the consent form
b.Cancel the scheduled ECT procedure ~
c. Proceed with the preparation for ECT based on implied consent
d. Inform the client about the risks of refusing the ECT
7. A nurse is caring fora client who reports that he is angry with his partner because she
thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he
becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating?
a. Rationalization
b. Denial
¢. Compensation
d.Displacement
8. A nursing is advising an assistive personnel (AP) on the care of a client who has major
depressive disorder. The AP states that he is irritated by the client’s depression. Which of
the following statements by the nurse is appropriate?
a. Please don’t take what the client said seriously when she is depressed
b.It's important that the client feel safe verbalizing how she is feeling
c. Everybody feels that way about this client so don’t worry about it
d. VIl change your assignment to someone who doesn’t have depressive disorder
9. A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
a. The child is 10years old
, b. The child is home-schooled
c. The has no siblings
d.The
———child has cystic fibrosis
10.A nurse is providing behavioral therapy for a client who has obsessive- compulsive disorder.
The client repeatedly checks that the doors are locked at night. Which of the following
instructions should the nurse give the client when using thought stopping technique?
a. Keep a journal of how often you check the locks each night
C. Aska family member to check the lock for you at night
d. Focus on abdominal breathing whenever you go to check the locks
11.A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the
following findings should the nurse anticipate administration of lorazepam/
aBr dycardia
b. Stupor
c. Afebrile
d. Hypertension
12. A nurse is creating a plan of care of a client who has anorexia nervosa.
Which of the following intervention should the nurse include in the plan?
a. Weigh the client twice per day
b. Prepare the client for electroconvulsive therapy
c. Set a weight gain goal of 2.2kg (5lbs) per week
A nurse Is caring for a client wha requires seclusion to prevent harm ta others on the unit. Which of the follawing is an appropriate action for the
nurse
to take?
() Document the client's behaviar prior 1o being placed In secusion,
© Assess the client's behavior once every hour.
© Ofter fuids every
2v
@ Owcuss with the client his inappropriate behavior prior to seclusion.
QUESTION 2
—
wvacuaty first?
© ot whe v whemichisn st s consed
@ & e s i wetretten anct wears o haarg ot
Q4 et who m i datcry and recring cepgen
Al ot P 4 A et ) Taanc SUSgmn
O a¢tion
QUESTION 3
A e @ Careg for & ter =t wmergerey SuparTeTt i the plan
1100
Tumpesaturn 16.8° C (0037 1}
Vwart rate 92/
Worpirat
1590 ®
uyien satisration 67w on romm s
Mesgir atory ¢
W 140090 mm g
wyen watunation 3% on rosm s
© e s ey 2 r
@ Doncuss wath the chent b inagpropriste hehawar prioe 10 seckision
QUESTION 4
, A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement
and the nurve offers a bed pan. The client states. “I've always used the bathroom ~ Which of the following respomes should the nurse make?
QUESTION 5
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the
nurse plan to use during the group session?
) Encourage clients 10 s a tmetine for thew own grieviny
Initiate
o discu to cope with changes
in tamily dynamics.
Assis 4 have been prevented
ourage chents from sharing negative asper el celationship
with the deceased persons.
QUESTION 6
A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
a. Conduct apregnancy test
b. Requests mental health consultation for the client
c. Provide atrained advocate to stay with the client
,6. Anurse is caring for a client who has major depressive disorder. After discussing the
treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but
will not sign the consent form. Which of the following actions should the nurse take?
a. Request that the client’s partner sign the consent form
b.Cancel the scheduled ECT procedure ~
c. Proceed with the preparation for ECT based on implied consent
d. Inform the client about the risks of refusing the ECT
7. A nurse is caring fora client who reports that he is angry with his partner because she
thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he
becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating?
a. Rationalization
b. Denial
¢. Compensation
d.Displacement
8. A nursing is advising an assistive personnel (AP) on the care of a client who has major
depressive disorder. The AP states that he is irritated by the client’s depression. Which of
the following statements by the nurse is appropriate?
a. Please don’t take what the client said seriously when she is depressed
b.It's important that the client feel safe verbalizing how she is feeling
c. Everybody feels that way about this client so don’t worry about it
d. VIl change your assignment to someone who doesn’t have depressive disorder
9. A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
a. The child is 10years old
, b. The child is home-schooled
c. The has no siblings
d.The
———child has cystic fibrosis
10.A nurse is providing behavioral therapy for a client who has obsessive- compulsive disorder.
The client repeatedly checks that the doors are locked at night. Which of the following
instructions should the nurse give the client when using thought stopping technique?
a. Keep a journal of how often you check the locks each night
C. Aska family member to check the lock for you at night
d. Focus on abdominal breathing whenever you go to check the locks
11.A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the
following findings should the nurse anticipate administration of lorazepam/
aBr dycardia
b. Stupor
c. Afebrile
d. Hypertension
12. A nurse is creating a plan of care of a client who has anorexia nervosa.
Which of the following intervention should the nurse include in the plan?
a. Weigh the client twice per day
b. Prepare the client for electroconvulsive therapy
c. Set a weight gain goal of 2.2kg (5lbs) per week
