Nur 213 Final Exam New Latest Version with Correct
Answer
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and
reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the
nurse interpret this behavior as a cue to modify the treatment plan?
1.
Suggesting a reduction of medication
2.
Allowing increased "in-room" activities
3.
Increasing the level of suicide precautions
4.
Allowing the client off-unit privileges as needed - CORRECT ANSWER 3
(pt who is moderately depressed and has only been in the hospital 2 days is unlikely to have such
a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the
decision to harm himself or herself. Suicide precautions are necessary to keep the client safe)
The emergency department nurse is caring for an adult client who is a victim of family violence.
Which priority instruction should be included in the discharge instructions?
1.
Information regarding shelters
2.
Instructions regarding calling the police
3.
Instructions regarding self-defense classes
4.
Explaining the importance of leaving the violent situation - CORRECT ANSWER 1
A female victim of a sexual assault is being seen in the crisis center. The client states that she
still feels "as though the rape just happened yesterday," even though it has been a few months
since the incident. Which is the most appropriate nursing response?
1.
"You need to try to be realistic. The rape did not just occur."
, 2.
"It will take some time to get over these feelings about your rape."
3.
"Tell me more about the incident that causes you to feel like the rape just occurred."
4.
"What do you think that you can do to alleviate some of your fears about being raped again?" -
CORRECT ANSWER 3
(trash response irl though)
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse
can best ensure client safety by which action?
1.
Requesting that a peer remain with the client at all times
2.
Removing the client's clothing and placing the client in a hospital gown
3.
Assigning to the client a staff member who will remain with the client at all times
4.
Admitting the client to a seclusion room where all potentially dangerous articles are removed -
CORRECT ANSWER 3
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client
may be suicidal?
1.
The adolescent gives away a DVD and a cherished autographed picture of a performer.
2.
The adolescent runs out of the therapy group, swearing at the group leader, and to her room.
3.
The adolescent becomes angry while speaking on the telephone and slams down the receiver.
4.
The adolescent gets angry with her roommate when the roommate borrows the client's clothes
without asking. - CORRECT ANSWER 1
A depressed client on an inpatient unit says to the nurse, "My family would be better off without
, me." Which is the nurse's best response?
1.
"Have you talked to your family about this?"
2.
"Everyone feels this way when they are depressed."
3.
"You will feel better once your medication begins to work."
4.
"You sound very upset. Are you thinking of hurting yourself?" - CORRECT ANSWER 4
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.
1.
"I'm afraid of spiders."
2.
"I keep reliving the robbery."
3.
"I see his face everywhere I go."
4.
"I don't want anything to eat now."
5.
"I might have died over a few dollars in my pocket."
6.
"I have to wash my hands over and over again many times." - CORRECT ANSWER 2 3 5
(Reliving an event, experiencing emotional numbness (facing possible death), and having
flashbacks of the event (seeing the same face everywhere) are all common occurrences with
posttraumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a
phobia. The statement "I have to wash my hands over and over again many times" describes
ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive
disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous
conditions)
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania.
Which client symptoms require the nurse's immediate action?
Answer
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and
reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the
nurse interpret this behavior as a cue to modify the treatment plan?
1.
Suggesting a reduction of medication
2.
Allowing increased "in-room" activities
3.
Increasing the level of suicide precautions
4.
Allowing the client off-unit privileges as needed - CORRECT ANSWER 3
(pt who is moderately depressed and has only been in the hospital 2 days is unlikely to have such
a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the
decision to harm himself or herself. Suicide precautions are necessary to keep the client safe)
The emergency department nurse is caring for an adult client who is a victim of family violence.
Which priority instruction should be included in the discharge instructions?
1.
Information regarding shelters
2.
Instructions regarding calling the police
3.
Instructions regarding self-defense classes
4.
Explaining the importance of leaving the violent situation - CORRECT ANSWER 1
A female victim of a sexual assault is being seen in the crisis center. The client states that she
still feels "as though the rape just happened yesterday," even though it has been a few months
since the incident. Which is the most appropriate nursing response?
1.
"You need to try to be realistic. The rape did not just occur."
, 2.
"It will take some time to get over these feelings about your rape."
3.
"Tell me more about the incident that causes you to feel like the rape just occurred."
4.
"What do you think that you can do to alleviate some of your fears about being raped again?" -
CORRECT ANSWER 3
(trash response irl though)
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse
can best ensure client safety by which action?
1.
Requesting that a peer remain with the client at all times
2.
Removing the client's clothing and placing the client in a hospital gown
3.
Assigning to the client a staff member who will remain with the client at all times
4.
Admitting the client to a seclusion room where all potentially dangerous articles are removed -
CORRECT ANSWER 3
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client
may be suicidal?
1.
The adolescent gives away a DVD and a cherished autographed picture of a performer.
2.
The adolescent runs out of the therapy group, swearing at the group leader, and to her room.
3.
The adolescent becomes angry while speaking on the telephone and slams down the receiver.
4.
The adolescent gets angry with her roommate when the roommate borrows the client's clothes
without asking. - CORRECT ANSWER 1
A depressed client on an inpatient unit says to the nurse, "My family would be better off without
, me." Which is the nurse's best response?
1.
"Have you talked to your family about this?"
2.
"Everyone feels this way when they are depressed."
3.
"You will feel better once your medication begins to work."
4.
"You sound very upset. Are you thinking of hurting yourself?" - CORRECT ANSWER 4
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.
1.
"I'm afraid of spiders."
2.
"I keep reliving the robbery."
3.
"I see his face everywhere I go."
4.
"I don't want anything to eat now."
5.
"I might have died over a few dollars in my pocket."
6.
"I have to wash my hands over and over again many times." - CORRECT ANSWER 2 3 5
(Reliving an event, experiencing emotional numbness (facing possible death), and having
flashbacks of the event (seeing the same face everywhere) are all common occurrences with
posttraumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a
phobia. The statement "I have to wash my hands over and over again many times" describes
ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive
disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous
conditions)
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania.
Which client symptoms require the nurse's immediate action?
