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A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My
mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which
response is appropriate for the nurse to make? - Answer -"It seems that you needed Bobby's help
to separate from your family
A client admitted 72 hours ago with a diagnosis of major depression presents for breakfast today
appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than
before. Which initial action should the nurse take after noting this client's behavior? - Answer -Ask
the client directly about the presence of any suicide-related thoughts.
A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the
client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity.
How can the doctor even think about doing this to her?" Which response by the nurse will best address
the daughter's concerns? - Answer -"It sounds as though you are very concerned. Let's discuss the
procedure."
A client admitted to the mental health unit after attacking his father for disturbing him at his computer,
interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my
computer project to save the world!" Which nursing response will have the greatest therapeutic impact?
- Answer -"I will be back to talk with you in 15 minutes after I complete nursing rounds."
A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety.
What should the initial nursing assessment focus on? - Answer -The client's physical condition
A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that
the client is coping ineffectively with the situation. Which are the most realistic goals for this client?
Select all that apply. - Answer -- The client will develop adaptive coping patterns.
- The client will identify a realistic perception of stressors
- The client will express and share feelings regarding the present crisis.
- The client will identify effective coping patterns that have worked in the past.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and
hyperventilating. What is the priority nursing action for this client? - Answer -Remain with the
client until the anxiety decreases.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should
the nurse implement initially? - Answer -Use an indirect light source and turn off the television.
,A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy.
The nurse should tell the client that he or she will likely start to see improvement in approximately what
time frame? - Answer -1 week after the 3rd treatment session
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? - Answer -"Wouldn't you
want to know if your daughter was having difficulties so you could help if you could?"
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would
stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying."
Which response by the nurse is therapeutic? - Answer -"You're feeling angry that your family
continues to hope for you to be cured?"
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which
statement by the client indicates a need for further teaching about the therapy? - Answer -"This
form of therapy provides a negative reinforcement when the stimulus is produced."
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a
hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot
see, a mental health consult is prescribed. The nurse plans care based on which condition that should be
the focus of this consult? - Answer -Conversion disorder
A client is admitted with a recent history of severe anxiety following a home invasion and robbery.
During the initial assessment interview, which statement by the client should indicate to the nurse the
possible diagnosis of posttraumatic stress disorder? Select all that apply. - Answer -- I keep reliving
the robbery."
- "I see his face everywhere I go."
- "I might have died over a few dollars in my pocket."
A client is participating in a therapy group and focuses on viewing all team members as equally
important in helping the clients to meet their goals. The nurse is implementing which therapeutic
approach? - Answer -Milieu therapy
A client is withdrawn, immobile and mute. Which appropriate action should the nurse should take? -
Answer -Sit beside the client and occasionally introduce open-ended questions.
A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking
antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention
addresses the priority sign/symptom? - Answer -Encourage frequent fluid intake and a high-fiber
diet.
A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at
night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? -
Answer -"I hear what you are saying, but I have no reason to believe your roommate steals."
, A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail
in my coffin." Which response by the nurse is therapeutic? - Answer -"You seem very distressed
over learning you have asthma."
A client who is watching television in the dayroom shares with the nurse that he has begun seeing his
mother being assaulted on the television screen. Which is the nurse's initialintervention? -
Answer -Turn off the television.
A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday
and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to
mind her own business." Which response by the nurse would be therapeutic? - Answer -"You need
to grieve, and expressing anger can be part of grieving."
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly
admitted client will be assigned to this client's room. Which client would be the best choice as a
roommate for the client with anorexia nervosa? - Answer -A client undergoing diagnostic tests
rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia
nervosa is most likely experiencing hematological complications, such as leukopenia.
A client with a history of anxiety appears to be in the second phase of crisis response. The nurse
prepares for which client behavior? - Answer -The client will employ new coping methods that will
resolve the problem.
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse
responds, knowing that the client's craving is a result of which factor? - Answer -Lack of naturally
occurring endorphins
A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to
the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be
therapeutic at this time? - Answer -What is causing you to behave so agitated?"
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that
she would like to buy some new clothes, but her finances are limited. Group members have brought
some used clothes to the client to replace the client's old clothes. The client believes that the new
clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse
evaluate this behavior? - Answer -Evidence of the client's disturbed body image
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is
very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've
been asked to do!" Which nursing interpretation is best for this situation? - Answer -An expected
coping mechanism
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement
supports the existence of an alcohol tolerance problem? - Answer -"I have a cocktail after work,
wine with dinner, and no more than 2 drinks to sleep.
Questions with Correct Answers Graded
Perfect Score Guaranteed Pass
A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My
mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which
response is appropriate for the nurse to make? - Answer -"It seems that you needed Bobby's help
to separate from your family
A client admitted 72 hours ago with a diagnosis of major depression presents for breakfast today
appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than
before. Which initial action should the nurse take after noting this client's behavior? - Answer -Ask
the client directly about the presence of any suicide-related thoughts.
A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the
client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity.
How can the doctor even think about doing this to her?" Which response by the nurse will best address
the daughter's concerns? - Answer -"It sounds as though you are very concerned. Let's discuss the
procedure."
A client admitted to the mental health unit after attacking his father for disturbing him at his computer,
interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my
computer project to save the world!" Which nursing response will have the greatest therapeutic impact?
- Answer -"I will be back to talk with you in 15 minutes after I complete nursing rounds."
A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety.
What should the initial nursing assessment focus on? - Answer -The client's physical condition
A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that
the client is coping ineffectively with the situation. Which are the most realistic goals for this client?
Select all that apply. - Answer -- The client will develop adaptive coping patterns.
- The client will identify a realistic perception of stressors
- The client will express and share feelings regarding the present crisis.
- The client will identify effective coping patterns that have worked in the past.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and
hyperventilating. What is the priority nursing action for this client? - Answer -Remain with the
client until the anxiety decreases.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should
the nurse implement initially? - Answer -Use an indirect light source and turn off the television.
,A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy.
The nurse should tell the client that he or she will likely start to see improvement in approximately what
time frame? - Answer -1 week after the 3rd treatment session
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? - Answer -"Wouldn't you
want to know if your daughter was having difficulties so you could help if you could?"
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would
stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying."
Which response by the nurse is therapeutic? - Answer -"You're feeling angry that your family
continues to hope for you to be cured?"
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which
statement by the client indicates a need for further teaching about the therapy? - Answer -"This
form of therapy provides a negative reinforcement when the stimulus is produced."
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a
hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot
see, a mental health consult is prescribed. The nurse plans care based on which condition that should be
the focus of this consult? - Answer -Conversion disorder
A client is admitted with a recent history of severe anxiety following a home invasion and robbery.
During the initial assessment interview, which statement by the client should indicate to the nurse the
possible diagnosis of posttraumatic stress disorder? Select all that apply. - Answer -- I keep reliving
the robbery."
- "I see his face everywhere I go."
- "I might have died over a few dollars in my pocket."
A client is participating in a therapy group and focuses on viewing all team members as equally
important in helping the clients to meet their goals. The nurse is implementing which therapeutic
approach? - Answer -Milieu therapy
A client is withdrawn, immobile and mute. Which appropriate action should the nurse should take? -
Answer -Sit beside the client and occasionally introduce open-ended questions.
A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking
antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention
addresses the priority sign/symptom? - Answer -Encourage frequent fluid intake and a high-fiber
diet.
A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at
night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? -
Answer -"I hear what you are saying, but I have no reason to believe your roommate steals."
, A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail
in my coffin." Which response by the nurse is therapeutic? - Answer -"You seem very distressed
over learning you have asthma."
A client who is watching television in the dayroom shares with the nurse that he has begun seeing his
mother being assaulted on the television screen. Which is the nurse's initialintervention? -
Answer -Turn off the television.
A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday
and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to
mind her own business." Which response by the nurse would be therapeutic? - Answer -"You need
to grieve, and expressing anger can be part of grieving."
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly
admitted client will be assigned to this client's room. Which client would be the best choice as a
roommate for the client with anorexia nervosa? - Answer -A client undergoing diagnostic tests
rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia
nervosa is most likely experiencing hematological complications, such as leukopenia.
A client with a history of anxiety appears to be in the second phase of crisis response. The nurse
prepares for which client behavior? - Answer -The client will employ new coping methods that will
resolve the problem.
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse
responds, knowing that the client's craving is a result of which factor? - Answer -Lack of naturally
occurring endorphins
A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to
the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be
therapeutic at this time? - Answer -What is causing you to behave so agitated?"
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that
she would like to buy some new clothes, but her finances are limited. Group members have brought
some used clothes to the client to replace the client's old clothes. The client believes that the new
clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse
evaluate this behavior? - Answer -Evidence of the client's disturbed body image
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is
very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've
been asked to do!" Which nursing interpretation is best for this situation? - Answer -An expected
coping mechanism
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement
supports the existence of an alcohol tolerance problem? - Answer -"I have a cocktail after work,
wine with dinner, and no more than 2 drinks to sleep.
