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A nurse in an emergency department is caring for a femail adolescent who has a
diagnosis of bulimia nervose and has a fainting episode during a ballet performance.
Which of the following statements by the parent acknowledges the client's diagnosis?
A. "She works so hard at ballet. Will she still be able to perform?"
B. "She won't let me take the trash from her room. I'm concerned about what she has in
there."
C. "She told me she was tired, so I did her chores for her today."
D. "She is happier with her appearance now that she's lost some weight." -correct
answerB. "She won't let me take the trash from her room. I'm concerned about what
she has in there."
The client might be binge eating and attempting to hide food containers, which is a
common behavior among clients who have bulimia nervosa. The parent's statement
indicates awareness of the client's behavior.
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appears withdrawn and fearful.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 administration is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitation behavior change
,D. Determine coping strategies that the client has used in the past -correct answerA.
Inform the client that this administration is confidential
According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse-client relationship.
A nurse is teaching coping strategies to a client who is experiencing depression related
to partner violence. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will spend extra time at work to keep from feeling depressed."
B. "I will talk about my feelings with a close friend."
C. "I will be able to learn how to prevent my partner's attacks."
D. "I will use meditation instead of taking my antidepressant." -correct answerB. "I will
talk about my feelings with a close friend."
Discussing feelings, such as fear and depression, with a support person is an effective
coping strategy and can provide the client with emotional support and other resources.
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following
statements should the nurse make?
A. "you probably want to hold your baby"
B. "I'll stay with you just in case you want to talk."
C. "I know how you must be feeling."
D. "It hurts now, but things will be better soon." -correct answerB. "I'll stay with you just
in case you want to talk."
This response demonstrates the therapeutic communication techniques of offering self
and indicates the nurse's interest in the client and a desire to understand the client's
feelings.
A charge nurse on a mental health unit is discussing client rights with a newly licensed
nurse. Which of the following statements should the charge nurse make?
A. "Clients can't refuse to take medications if they are admitted involuntarily."
B. "You can notify a client's family if they are admitted involuntarily."
C. "Clients who are admitted involuntarily maintain the right to give informed consent for
procedures."
D. "You can remove a client's privileges if they are admitted involuntarily and refuse to
attend therapy sessions." -correct answerC. "Clients who are admitted involuntarily
maintain the right to give informed consent for procedures."
Clients who are admitted involuntarily maintain the right to give informed consent for
treatment. They also have the right to give informed consent for procedures.
A nurse is caring for a child who has conduct disorder and is behaving in a destructive
manner, throwing objects, and kicking orders. Which of the following therapeutic nursing
interventions is the priority?
, A. Encourage expression of feelings
B. Support the child's attendance at an assertiveness training group
C. Assist the child to perform relaxation breathing
D. Reduce environmental stimuli -correct answerD. Reduce environmental stimuli
The greatest risk to the child and others is harm. Therefore, the nurse's priority
intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior
and prevent injury.
A nurse in a community health center is teaching families of clients who have post-
traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the
following manifestations should the nurse include?
A. Repeatedly talks about the traumatic incident
B. sleeps excessively
C. experiences feelings of isolation
D. uses repetitive speech -correct answerC. experiences feelings of isolation
The nurse should expect clients who have PTSD to feel estranged and detached from
others.
A nurse is assessing a client for risk factors for the development of depression. The
nurse should identify that which of the following factors places the client at an increased
risk for depression?
A. The client is married
B. The client recently received a promotion at work
C. The client has COPD
D. The client is a male -correct answerC. The client has COPD
The nurse should identify that clients who have a chronic medical illness are at an
increased risk for the development of depression.
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following
laboratory findings should the nurse expect?
A. Increased creatine phosphokinase (CPK)
B. Increase low-density lipoproteins (LDL)
C. Decreased fasting blood glucose
D. Decreased aspartate aminotransferase (AST) -correct answerA. Increased creatine
phosphokinase (CPK)
An increase in CPK, a muscle enzyme released when muscle tissue is damaged,
occurs with cardiomyopathy.
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's plan of care?
A. Offer the clients various choices for meal selection
B. Assign different nursing personnel for each shift