HC3B Exam 1 | Complete Solutions (Verified Answers)

HC3B Exam 1 | Complete Solutions (Verified Answers) An adult experiencing a recent exacerbation of ulcerative colitis tells the nurse, "I had an accident while I was at the grocery store. It was so embarrassing." Select the nurse's therapeutic response. A) "Most grocery stores have public restrooms available." B) "Tell me more about how you felt when that happened." C) "People usually have compassion about those types of events." D) "Your disease is now in remission so that is not likely to happen again." A nurse counsels a widow whose husband died 5 years ago. The widow says, If I'd done more, he would still be alive." Select the nurse's therapeutic response. A) "I understand how you feel after such a terrible loss." B) "That was a long time ago. Now it's time to move on with your life." C) "You did a very good job of caring for him, especially because he was sick for so long." D) "Your husband was 82 years old with severe chronic obstructive pulmonary disease." A patient has been out of work for 3 weeks with a major illness and anticipates another month of recovery. The patient tells the nurse, "I'm trying to keep up with my work email from home. They hired a new person in my department, but that person has no experience." Select the nurse's therapeutic response. A) "It sounds like you're saying you are worried about your job security." B) "No one expects you to keep pace with your job while you're recovering." C) "Your employer is required to hold your job for you while you're on sick leave." D) "Don't worry about your job right now. It's more important for you to recover." In which nurse-patient interaction would it be appropriate for the nurse to consider using touch? A) Comforting a tearful patient of Japanese heritage B) Counseling a child who was physically abused by a parent C) Welcoming a person of Hispanic heritage to a new group session D) Interacting with a Native American who has a hearing impairment A nurse prepares a patient in a rural community for an initial telehealth visit with the HCP. Select the nurse's priority action. A) Ensure that the patient's rights to privacy are respected B) Ask the patient, "How much do you know about the Internet?" C) Inform the patient, "This experience will be like appearing on a television." D) Advise the patient, "You will be able to hear, but not see, your health care provider." Which comment by the nurse would be appropriate to begin a new nurse-patient relationship? A) "Which of your problems is most serious?" B) "I want you to tell me about your problems." C) "I'm an experienced nurse. You can trust me." D) "What would you like to tell me about yourself?" A neighbor telephones the nurse daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ? A) Suggest the neighbor call other people in the community B) Say to the neighbor, "I can talk to you for 15 minutes twice a week." C) Use the telephone's caller ID to screen calls from the neighbor D) Tell the neighbor, "You should discuss these concerns with your personal physician rather than me." A patient has been oppositional, demanding, and resistant to working on goals. A mental health nurse tells the nursing supervisor, "We finally had a serious talk. I let that patient know it's time to get right with God and stop this behavior." Recognizing the nurse's actions were not acceptable, select the supervisor's responding action. A) Review the facility policies regarding patient's rights with the nurse B) Ask the nurse about documentation related to this patient interaction C) Schedule the nurse for a staff development activity on cultural sensitivity D) Work with the nurse to prepare and analyze a process recording of the interaction A nurse participating in a community health fair interviews an adult who has had no interaction with a health care professional for more than 10 years. The adult says, "I like to keep to myself. Crowds make me nervous." Which action should the nurse employ? A) Refer the adult for a full health assessment B) Explore the adult's family and social relationships C) Ask the adult, "How do you feel about the quality of your life?" D) Explain to the adult, "We can help you feel better about yourself." A few nurses are privately discussing patients under their care. Which nurse's comment indicates the need for clinical supervision regarding countertransference? A) "My patient is always asking my permission to do something, just like a child." B) "When our unit is understaffed, it seems like we have more incidents of disruptive behavior." C) "My patient tries to tell me what to do all the time. I got a divorce because my spouse used to do that." D) "Our patients have had so many life experiences. I find myself feeling sympathetic sometimes." The school nurse assesses four adolescents who appear to have a healthy weight. Which comment would lead the nurse to explore further for an eating disorder? A) "I usually try to exercise 30 minutes a day." B) "I know everything in my life will be better once I lose 15 more pounds." C) "I forgot my lunch today, so I will only be eating an apple." D) "I know I shouldn't eat potato chips, but I just love them." A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? A) "I look good because whenever I overeat, I purge myself." B) "I love sweets. I make myself throw up so I can eat more." C) "I've lost 60 pounds, but I'm still a size 2. I want to be a size 0." D) "I've hidden my eating disorder from everyone, even my parents." While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? A) Report the clinical observation to the nursing supervisor B) Ask the psychiatric technician, "What did you mean by that comment?" C) Privately discuss the importance of sensitivity with the psychiatric technician D) Immediately interrupt the interaction between the patient and psychiatric technician Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? A) "You need to gain weight to become healthier." B) "Your world would not change if you gained a few pounds." C) "Tell me how your world would be different if your were fat." D) "Your attractiveness is not defined by a number on the scale." A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's lab results, as follows: - Sodium: 143 mEq/L - Potassium: 3.1 mEq/L - Chloride: 102 mEq/L - Magnesium: 2.2 mEq/L - Calcium: 8.4 mg/dL - Phosphate: 3.0 mg/dL The nurse should take which action next? A) Measure the patient's body temperature B) Inspect the patient's skin and sclera for jaundice C) Assess the patient's mucous membranes for erosion D) Auscultate the patient's heart rate, rhythm, and sounds An ED nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? A) Leathery facial tone B) Injuries in a bikini pattern C) Reluctance to be examined D) Lack of eye contact with the nurse An ED nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services? A) "We do not believe in the immunization of our children." B) "This child is always creating problems for the family." C) "Our child would rather play alone than with other children." D) "We homeschool our children in order to include religious education." A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? A) Another beating by the abusive partner B) Love, gifts, and praise from the abusive partner C) A brief period during which the partners ignore each other D) The abusive partner leaves the relationship for a short time The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance? A) "Sometimes I get so discouraged and frustrated with my job." B) "It's incredible that anyone could hurt a child or elderly person." C) "The abuser was probably a victim of abuse at some point in life." D) "I hope the abuser gets victimized so they know what it feels like." A university football coach invites the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include? A) Appropriate behavior with intimate partners B) University resources for counseling and support C) The importance of role modeling for children and teens D) Public recognition of children with life-threatening illnesses An elderly widow tells the nurse, "Since my sister-in-law's death, her husband has been making advances toward me. He tried to come into my home with a bottle of wine. Even though he's family, I'm afraid of what might happen if I let him in." Which action should the nurse take first? A) Support the widow to clarify her thoughts and feelings about the situation B) Explain to the widow how to obtain an order of protection (restraining order) C) Positively reinforce the widow for addressing the problem with a caring professional D) Educate the widow about sexual assault and violence, including the importance of prevention An ED nurse talks with a newly admitted victim of reported rape. Which communication should the nurse offer to comfort the patient? A) "You are safe now. I will stay with you in this private room." B) "Would you like your friend to stay with you during your examination?" C) "You made a good decision to come to the hospital after you were raped." D) "What questions do you have about your examination by the sexual assault nurse examiner?" A patient tells the nurse, "I was raped 8 years ago but never told anyone. Nevertheless, the memories haunt me every day. I should be over it by now." Which comment should the nurse offer next? A) "It sounds like you're judging yourself for continuing to struggle with your reaction." B) "Rape is criminal behavior. You should have reported the incident to law enforcement." C) "Are you now ready to engage in counseling to deal with your reactions to this experience?" D) "Although it's important to learn from such life events, it's more important to put things in the past." An ED nurse prepares to discharge a victim of reported rape. Which comment by the victim indicates that the nurse's teaching was effective? A) "I should bathe frequently over the next week." B) "I am required to follow up with law enforcement." C) "It's important for me to follow up with counseling." D) "I should delay any sexual activity for at least 3 months." A victim of reported sexual assault tells the nurse, "This was entirely my fault. I should have never gone to that party alone." Which response by the nurse is most therapeutic? A) "This was a frightening experience for you." B) "What do you think you should have done differently." C) "Would you like to tell me more about what happened?" D) "It sounds like you're blaming yourself for the assailant's behavior." Select the completion of the following sentence that demonstrates that an adult is coping in a healthy way: "I am feeling so angry right now ... A) I'm afraid I'm going to cry." B) I would like to punch something." C) I want to talk to someone about it." D) I want to curl up and sleep for a long time." In a hostile voice, a patient experiencing mania yells at the nurse: "You will listen to me and not interrupt. I have some really important stuff to say. I'm tired of you nurses and doctors acting like you have all the answers." To facilitate effective communication, which initial response should the nurse provide? A) "You are our patient, so we always listen to you." B) "I can talk with you better if you use a calm voice." C) "It's our job to help you get through this manic episode." D) "Patients have an important role in treatment planning." A female nurse is appointed to a committee with seven men. At the beginning of the meeting, the chairman asks the nurse to be the secretary. The nurse responds, "No. You're just asking me to be secretary because I'm the only woman here." Which response would have been more effective? A) "There are others more qualified than I am to be secretary." B) "I would be glad to perform another role for our committee." C) "I'm probably overreacting, but I find your request offensive." D) "Thank you for asking, but your request is sexually discriminatory." An 8-year-old tells a parent, "I like to scare kids at school by showing them pictures of clowns. Some kids are terrified." How should the nurse counsel the parents regarding this behavior? A) Recommend family therapy for the child, siblings, and parents B) Suggest the parents enroll the child in an anger management program C) Educate both parents about bullying, including possible origins and long-term effects D) Teach the parents about the developmental phase and tasks for an 8-year-old child. A woman experienced a double mastectomy yesterday. Now she cheerfully says to the nurse, "I didn't need those things anyway. No more wet T-shirt contests for me!" How should the nurse interpret this comment? A) The patient is realistically accepting her loss B) The comment is sarcastic, which may reflect anger C) The patient is experiencing a distorted body image D) The comment suggests guilt regarding prior behavior The nurse is caring for four clients who have been recommended to consider bariatric surgery. Which assessment data require immediate nursing intervention? A) BMI of 23 with gastrointestinal reflux B) BMI of 36 with hypertension C) BMI of 40 with type II diabetes D) BMI of 43 with sleep apnea A client with obesity tells the nurse, "My genes are the only thing that have made me obese." What is the appropriate nursing response? SATA. A) "Genes can contribute to obesity." B) "Tell me about your family history." C) "Let's talk about your nutrition intake." D) "Have you considered bariatric surgery?" E) "How do you feel about physical activity?" F) "What lifestyle modifications have you tried?" What discharge teaching will the nurse provide to a client who had gastric bypass surgery? SATA. A) Be certain to stay hydrated by drinking water B) Solid food can be introduced back into the diet in a week C) Report any back, shoulder, or abdominal pain to the surgeon D) You are likely to have little urine output for the first few weeks E) Each of your meals should initially contain about 5 tablespoons of food Which statement made by the nurse best demonstrates a core concept of patient- and family-centered care? A) "Would you prefer I call you by your first name?" B) "Would you like to go with the group today to see a movie?" C) "Let me see if I understood your concerns about your medications." D) "Today I'll plan to spend time with you discussing your treatment plan." Rationale: The core concepts of patient- and family-centered care consist of (A) dignity and respect, (B) information sharing, (C) patient and family participation, and (D) the feeling of being heard and understood by patients. While all the options demonstrate a component of this form of care, clarifying an understanding of the client's concerns demonstrates the best and most basic form of patient centered care. Which statement by the nurse best confirms the relationship being maintained with the client is a therapeutic one? A) "Do you agree with me that we need to focus on your anger issues?" B) "I'll plan to meet with you again tomorrow at our regular time." C) "I'm sure you will get significant benefit from attending the group I suggested." D) "Can you give me some examples of how your coping skills have improved?" Rationale: The focus of the therapeutic relationship needs to be on the patient's ideas, experiences, and feelings. Inherent in a therapeutic relationship is the nurse's focus on significant personal issues introduced by the patient during the clinical interview. Which statement by the nurse demonstrates a blurring of boundaries with a client diagnosed with depression? A) "The client is just too depressed to shower and dress today." B) "Today we discussed the impact of depression on family members." C) "The client talked about an uncle who was depressed and committed suicide." D) "I'm concerned that the client's depression has been the cause of marital problems." Rationale: The nurse is demonstrating over-helping by determining the client doesn't need to shower because of the depression. This, along with controlling and narcissism on the part of the nurse, is an indicator of blurring boundaries. A nurse who is comfortable and confident with the interviewing process will effectively use which communication technique? A) Avoiding topics that could possibly be embarrassing B) Relying on verbal rather than nonverbal communication C) Personally fills each void in the conversation D) Allowing for moments of uninterrupted silence A client is seeking treatment in the ED after a sexual assault. Which notation made by the ED nurse demonstrates appropriate nonjudgmental documentation? A) An alleged sexual assault inside a local parking garage was made by the client B) No acute emotional distress during assessment was noted C) Treatment for facial abrasions was refused D) Physical evidence supports that vaginal penetration occurred Which client-focused change will the nurse identify as a sign of possible escalation of anger? A) A client that had been calm and quiet becomes talkative and loud B) A manic client becomes withdrawn C) An impulsive client demonstrates introspection D) A depressed client begins to cry A client became angry with a staff member and began throwing objects at others in the unit. Which question will the nurse manager ask the staff in order to address the goals of the debriefing of the incident that focuses on client care? A) "Were the unit's policies on managing violence followed?" B) "What injuries resulted from the violence?" C) "When did the violence begin?" D) "What was the client's reasoning for the violent behaviors?" After the admission interview and assessment, the ED nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused?" A) Insist that the child be further assessed without the parents being present B) Provide the child with suggestions of other possible examples of abuse C) Allow the child to pick one parent to be present during the remaining examination D) Delay the assessment until the appropriate child protection authorities are present A client has expressed great concern over "feeling like I'm going crazy" since experiencing anxiety, depression, and nightmares after being sexually assaulted. What response will the nurse make initially to address the client's concerns? A) "Let's talk about how these symptoms are making you feel and especially how they are making you feel crazy." B) "What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted." C) These are common feelings after being assaulted. Fortunately, you are not going crazy so try not to worry about that." D) "What you are experiencing is common among sexual assault victims. It's not a result of going crazy." Which behavior is an early sign of an abusive personality? SATA. A) Verbally abusive B) Jealous, controlling C) Enforces rigid sex roles D) Hypersensitive, easily insulted E) Isolates partner from family and friends F) Makes others responsible for their feelings Which action would the nurse take when interacting with an adolescent who has anorexia nervosa? A) Follow unit guidelines B) Maintain constant contact C) Demonstrate sympathy D) Focus on a healthy intake Which rationale describes the reason the nurse would ask a client who has been raped to describe what happened? A) This information will help the nursing staff give legal advice and provide counseling B) Talking about the assault will help the client see how actions have led to the event C) It will let the client put the event in better perspective and help begin the resolution process D) Discussing the details will keep the client from concealing the intimate happenings during the assault Which response would the nurse make to help a depressed client who is crying? A) "Does crying help?" B) "I know that you're upset." C) "Tell me what you're feeling now." D) "Do you want to tell me why you're crying?" Which response would the nurse make to a cocaine addict remanded for rehabilitation by the court who curses at his or her spouse and tell the spouse to go home, causing the spouse to leave in tears? A) "You are very angry right now." B) "Let's talk about what just happened." C) "Let's go to your next scheduled activity." D) "You should go to the gym to use the punching bag." Which nursing intervention would be priority in the period immediately after an emaciated young teenager with anorexia nervosa is admitted to the hospital for starvation? A) Ensuring that the child's rest and nutrition needs are met B) Correcting the child's fluid and electrolyte imbalances C) Obtaining more data about the child's diet and exercise program D) Completing an assessment of the child's physical and family status Which instructions would the nurse share with a housekeeping staff member who reports that the client with anorexia nervosa has food hidden in the room? A) Point this out to the client and remove the food B) Report it to the nursing staff if it happens again C) Disregard this finding because it's a common behavior in clients with anorexia D) Keep a record of when this happens and report it to the nursing staff weekly Which response would the nurse make to a depressed client who tells the nurse, "I want to die." A) "You would rather not live." B) "You're not alone in feeling this way." C) "When was the last time you felt this way." D) "Do you believe that there's a life after death?" Which response would the nurse make when obtaining a health history from a client who is known to be verbally abusive and says, "You're ugly, and you're probably stupid, too. Why am I stuck with you?" A) "It doesn't matter what you think, because I know I'm a capable nurse." B) "Tell me more about why my caring for you today is so upsetting to you." C) "If you like, I will arrange to switch assignments so you can have another nurse." D) "You are talking inappropriately, so I'm going to leave and will come back when you stop being verbally abusive." Which action would the nurse take for an adolescent client with anorexia nervosa? A) Reward weight gain by increasing privileges B) Discuss the importance of eating a balanced diet C) Encourage the client to include high-calorie foods in the diet D) Suggest family therapy to focus on the client's behavior Which nursing intervention would be essential for a newly admitted client with bulimia nervosa? A) Check on the client continually B) Observe the client during meals C) Teach the client to measure intake and output D) Involve the client in developing a daily meal plan Which action would the nurse take to establish a trusting relationship with a client who is using paranoid ideation? A) Being available on the unit but waiting for the client to approach B) Seeking the client out frequently to spend long blocks of time together C) Sitting on the unit and observing the client's behavior throughout the day D) Calling the client into the office to establish a contract for regular therapy sessions Which response would the nurse make to a client who tells the nurse, "A man is speaking to me from the corner of the room. Can you hear him?" A) "What's he saying to you? Does it make any sense?" B) "Yes, I hear him, but I can't understand what he's saying." C) "I don't hear him. There's no one in the corner of the room." D) "No, I don't hear him, but is it making you uncomfortable to hear him?" Which response would the nurse make to a client who has been acting out for several weeks and says, I'm really sorry about how I've acted. I'll bet everyone thinks I'm an idiot."? A) "You're wondering how others will react to you now." B) "Some clients are concerned that you might lose control again." C) "Everyone feels foolish sometimes; you didn't deliberately act that way." D) "Nobody thinks you're a fool; everyone recognized that you were really struggling to keep control." Which nursing intervention would help a client who exhibits physical symptoms when stressed? A) Limiting discussion about the problem B) Providing information regarding medical care C) Teaching the client how to eliminate stress at home D) Assisting the client in developing new coping mechanisms Which initial action would the nurse take to provide a therapeutic environment for a client who is withdrawn and reclusive? A) Foster a trusting relationship B) Administer medications on time C) Involve the client in a group with peers D) Remove the client from the family home The nurse hears a child who was not invited to a sleepover say, "I have better things to do than go that sleepover." Which defense mechanism would the nurse conclude the child is using? A) Denial B) Projection C) Regression D) Rationalization Which response would the nurse make to a depressed, crying client on the evening of admission? A) "You're crying. Let's talk about it." B) "Let me get a cup of coffee; then we can talk." C) "Visitors will be here soon; you'd better get ready." D) "You'll feel better soon. Come to the sitting room with me." Which response would the nurse make to a client who says, "I'm a terrible, evil person. The voices are telling me that God needs to punish me."? A) "God is loving and won't punish you." B) "Those voices you're hearing are a fantasy." C) "Tell me what you're thinking about yourself." D) "You aren't wicked-both God and I love you." Which instruction would the nurse suggest to a 14-year-old girl who suspects her friend is using self-induced vomiting to keep weight down? A) Confront her friend with her suspicions B) Talk to the school nurse about her concerns C) Inform the girl's mother about her daughter's behavior D) Watch a while longer before doing anything that might ruin the friendship Which response would the nurse make to a client who has been attending a day treatment facility for 1 month with depressive disorder and is to be discharged in a week? A) "We have just a few sessions left. I'm really pleased with your progress." B) "Your discharge date has been set for next week. That's wonderful news." C) "There are 5 sessions remaining. We need to start making plans to end our sessions." D) "I understand that your discharge is set for next week. I'm wondering how you feel about that?" Which conclusion would the school nurse make about a female teenager who has anorexia nervosa and states that she thinks she is pregnant even though she has had intercourse only once, more than a year ago? A) Is using magical thinking B) Is submitting to peer pressure C) Is lying about the last time she had intercourse D) Is lacking knowledge that the disease can cause amenorrhea Which reason would likely be the cause for a 65-inch tall 15-year-old girl weighing 80 lb being admitted to a mental health facility? A) A desire to control her life B) The wish to be accepted by her peers C) The media's emphasis on the beauty of thinness D) A delusion in which she believes that she must be thin Which communication technique would the nurse be using when he or she states, "Let's see whether we mean the same thing." to a client who is not making sense? A) Reflecting feelings B) Making observations C) Seeking consensual validation D) Attempting to place events in sequence Which approach would the nurse use for the involved parent who has a child diagnosed with Munchausen syndrome by proxy? A) Confrontation B) Open communication C) Health teaching about childrearing D) Validation of the child's physical status Which response would the nurse make during the admission procedure for a client who cries out at intervals, "No, no! I didn't kill him! You know the truth-tell that police officer! Please help me!"? A) Listening attentively and assuming an expression of disbelief B) Saying, "I want to help you. I realize that you must be very frightened." C) Sitting quietly and refraining from responding to the client's statements D) Replying, "Don't be so upset. No one is talking to you; those voices are part of your illness." Which initial action would the nurse take for a young client with anorexia nervosa who phones home just before each mealtime and then refuses to eat food that has gotten cold? A) Insist that the client eat the food B) Revoke the client's phone privileges C) Hang up the phone when meals are served D) Schedule a family meeting to discuss the problem Which intervention would the nurse include in the plan of care for an adolescent with anorexia nervosa who is admitted to the psychiatric unit? A) Limit opportunities for decision-making B) Provide supervision during and after mealtimes C) Arrange for a physical exercise program with time to complete it D) Request that parents keep their visits to a minimum early in treatment Which action would the nurse take for an adolescent who has been admitted to the psychiatric hospital with a diagnosis of anorexia nervosa? A) Schedule an endocrinology consult because of amenorrhea B) Confront those behaviors that reflect an inflated self-importance C) Arrange for psychotherapy sessions to help develop a desire to accommodate others D) Develop a contract to achieve a weekly weight gain, with consequences for non-achievement Which response would the nurse make to a confused, hallucinating client who says, "My arms are turning to stone."? A) "May I examine your arms?" B) "When did this feeling first start?" C) "That's a rather unusual sensation." D) "It can be frightening to feel that way." Which assessment data would the nurse find in a client who was recently admitted with a diagnosis of bulimia nervosa? A) Amenorrhea in postmenarchal female B) Lack of control over bing-eating episodes C) Body weight less than 85% of that expected D) Inability to purge in public places after eating Which client finding would indicate that the therapy is beginning to be effective in a client with anorexia nervosa? A) Hides food in clothes pockets B) States that the hospitalization has been helpful C) Has gained 6 lb since admission 3 weeks ago D) Remains in the dining room eating for 1 hour after others have left Which short-term outcome would the nurse use for a client with bulimia nervosa who at times feels helpless in regard to the eating disorder? A) Practices effective socialization skills B) Perceives the body shape as acceptable C) Decreases preoccupation with delusional thoughts D) Verbalizes the desire to increase control over stressful situations