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With 60 multiple choices questions and answers
1. A nurse is assessing a family's dynamics during a counseling session. Thenurse
should recognize which of the following findings as an indication of a boundary issues?
A. An adolescent family member who questions parental authority
B. A family with three generations in the same household
C. Older children who are responsible for their younger siblings
D. Two adults and their children from prior relationships in the same house-hold:
Correct: C
- This is an example of enmeshed boundaries in which there are no distinctions
between the roles of family members.
A - incorrect - An adolescent who questions parental authority is demonstrating
appropriate behaviors for developmental age
B - incorrect - This scenario occurs in many households, not indication of boundaryissue
D. This is an example of a blended family, not indication of boundary issue
2. A nurse is performing an admission assessment on a client and notices that the client
appears withdrawn and fearful. To establish a trusting nurse=client relationship, which
,of the following actions should the nurse take first?
A. Inform the client that this admission is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitating behavioral change
D. Determine coping strategies that the client used in the past: A - CORRECt
- According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse-client relationship.
B - Incorrect The nurse should introduce the client to other clients in the day room to help
the client interact with others during the working phase of the nurse-client relationship.
However, evidence-based practice indicates that the nurse should takea different action
first.
C. INCORRECT The nurse should assist the client with behavioral change during theworking
phase of the nurse-client relationship. However, evidence-based practice indicates that the
nurse should take a different action first.
D. Incorrect The nurse should determine what coping strategies the client usedin the
past during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take a different action first.
,3. A nurse is performing a cognitive assessment to distinguish delirium form dementia
in a client whose family reports episodes of confusion. Which of the following
assessment findings supports the nurse's suspicion of delirium?
A. Slow onset
B. Aphasia
C. Confabulation
D. Easily distracted: D - CORRECT
- Extreme distractibility is a hallmark manifestation of delirium.
A - INCORRECT
Delirium has an acute onset. Dementia is a slow, progressive decline.
B. INCORRECT
Aphasia is a manifestation of dementia
C. INCORRECT
Confabulation is a manifestation of dementia.
4. A nurse is caring for an older adult client who is experiencing delirium. Which of
the following interventions should the nurse include in the client'splan of care?
A. Offer the client various choices for meal selection
B. Assign different nursing personnel for each shift
C. Permit the client to perform daily rituals to decrease anxiety
D. Maintain an environment that has low lighting: C - CORRECT
The nurse should provide a client who has delirium with a plan of care that decreasesagitation
, and anxiety by permitting the client to perform daily rituals.
A- INCORRECT
The nurse should provide a client who has delirium with a plan of care that decreasesagitation
and anxiety by limiting the choices the client is asked to make.
B - The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by providing consistent nursing personnel.
D - The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by providing a well-lit environment.
5. A nurse is planning care for a client who has bipolar disorder and is experiencing
mania. Which of the following interventions should the nurseinclude in the plan of
care?
A. Encourage the client to participate in group therapy