NURSING 322 CAPSTONE REVIEW PACK-
EXAM PREP WITH VERIFIED ANSWERS
At the end of a group therapy session, a client who is hospitalized for psychosis falls to the
floor when attempting to stand. What intervention should the nurse implement first?
Ask a group member to seek help.
Which nursing intervention should the nurse implement with parents who experience a
fetal demise and express the wish not to see the baby?
Keep the body available for a few hours in case they change their minds.
An adult female who is married and works full-time in a factory has been absent from
work for three days at a time on several occasions. Each time she returns to work, she
wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational
health nurse. What assessment question should the nurse use?
How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate
a referral to which healthcare team member?
Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care?
Focus on the client's positive or negative feelings toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch where
hair was lost from her scalp. She is accompanied by her husband who tells the nurse that
his wife caught her hair on the railing and pulled it out when she fell down the stairs. The
husband is solicitous of his wife and quickly answers questions on her behalf. He attempts
to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us
apart." What is the priority nursing intervention?
Require the husband to leave the cubicle while the client is being treated.
A female client with severe depression is given information about the risks, benefits,
alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the
informed consent for treatment. After the client's family leaves, the client tells the nurse, "I
signed the papers because my husband told me I will be deported if my depression is not
cured." What information should the nurse report to the healthcare provider?
The client's consent may have been coerced.
A male client with severe orthopedic injuries following a motor vehicle collision is irritable,
angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the
client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which
intervention is best for the nurse to implement?
Provide information about infection prevention.
The nurse is assessing a client with a history of borderline personality disorder. Which
question should the nurse include in the assessment?
Do you frequently have temper tantrums?
,During the admission of a male client to the mental health unit, the client tells the nurse
that he had a panic attack today and ran out of the physician's office. Which question is
most important for the nurse to ask this client?
Have you had any thoughts of hurting yourself?
The nurse completes an emergency admission of a male client with schizophrenia who has
not been taking his antipsychotic medications. The client is pacing, is extremely irritable,
and has a blood pressure of 146/96. What is the priority nursing action?
Reevaluate the client's blood pressure in an hour.
A young adult female client with panic disorder arrives in the Emergency Center with a 4-
day history of chest pain that began when her boyfriend left her. Initial assessment reveals
normal cardiopulmonary findings. Which information is most important for the nurse to
obtain?
Drugs taken in last 7 days.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells
the nurse, "There wasn't anything I could do to stop her drinking this morning." What
intervention should the nurse take at this time?
Tell the client that therapy cannot take place while she is intoxicated.
The nurse is planning care for a client with major depression who is admitted to the unit
after a recent suicide attempt. Which intervention has the highest priority for inclusion in
this client's plan of care?
Search the client's personal belongings.
A male client is brought to the emergency department by a police officer, who reports the
client was "disturbing the peace" by running naked in the street, striking out at others, and
smashing car windows. Which behaviors should the client demonstrate to determine if he
should be evaluated for involuntary commitment? (Choose all that apply.)
Threats to kill his friend, hears voices telling him to kill himself, reports he has not needed a bath
in 4 months and says he has not eaten in 3 days.
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and
motionless. What is the priority nursing problem?
High risk for fluid and electrolyte imbalance.
A client who had a miscarriage at 10-weeks gestation tells the nurse that she already
purchased some baby things and picked out a name. After the surgical dilation and
curettage (D&C), the client wants to go home as soon as possible. Based on the client's
statements, which action should the nurse implement?
Ask the client what name she had picked out for the infant.
A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal
again." How should the nurse respond?
"Tell me more about how things are with you."
A client is scheduled to complete a positron emission tomography (PET) scan. The client
asks the nurse to explain the reason the test was prescribed. How should the nurse
respond?
Results show activity in various portions of the brain.
Which technique is the most important therapeutic tool a nurse should use to provide
quality care to a psychiatric client?
Self-analysis
,A client with substance abuse is admitted to the mental health unit. Which action should be
implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)?
Collect a complete substance abuse history.
A female client with bipolar disorder, manic phase, is planning weekend activities with the
other clients on the unit. The client interrupts the group, insists that they change their
plans to a disco party, and begins to curse loudly when the group refuses to change the
plans. Which intervention should the nurse implement?
Escort the client to a quieter place
A client with a history of alcoholism is admitted with a compound fracture of the femur
after falling down the previous night. What additional assessment should be the priority
focus for the nurse?
Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.
The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago.
Which finding is most critical for the nurse to report to the healthcare provider?
Global confusion and inability to recognize family members.
A male client who is on the liver transplant list is called to the unit for a possible
transplant. When learning that the donor organ is no longer available, the client slams
doors and shouts vulgarities about his situation. What action should the nurse implement?
Express concern over his disappointment.
The nurse is caring for a female client who is admitted for depression with the nursing
diagnosis, "Self-esteem, chronic low." Which client response indicates to the nurse that the
client has improved self-esteem?
Identifies own strengths
A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will
always be this way and that there's no hope for me." What information should the nurse
provide?
Panic disorder is treatable in a number of different ways, including medication.
Which client outcome during hospitalization indicates improvement for a client who is
admitted with auditory hallucinations?
Tells when voices decrease.
Which action is most important for the nurse to implement during the initial interview for
a client who is admitted to the mental health unit?
Establish rapport in each phase of the nurse-client relationship.
Which statement made by an adolescent in group therapy should the nurse identify as a
priority in planning care?
I have a necktie in my room that I can use to hang myself.
A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is
released from the hospital. What action should the nurse implement?
Inform the healthcare provider and document the plan in the record.
Which client statement should the nurse identify as most typical of a client with mania?
I manage our finances great because I buy in big quantities.
A client is pacing in the hall near the nurses' station and swearing loudly. What response is
best for the nurse to provide?
You seem pretty upset. Tell me about it.
, A client actively involved in substance addiction therapy frequently relapses into
benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able
to kick this habit." How should the nurse respond?
The client must participate in making decisions about one's own physical and mental health.
Which action should the nurse implement during the termination phase of the nurse-client
relationship?
Help summarize accomplishments.
The daughter of an older male client tells the nurse that her father is becoming increasingly
forgetful. Which finding indicates that the client needs further evaluation of cognitive
function?
Cannot mentally retrace objects that were recently misplaced.
Which action should the nurse implement first for a client experiencing alcohol
withdrawal?
Prepare the environment to prevent self-injury.
The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT)
a half hour ago. Which action should the nurse implement first?
Monitor vital signs.
The client with depression asks the nurse, " What are neurotransmitters? My doctor thinks
my problem may lie with the neurotransmitters in my brain." What information should the
nurse use to support an explanation of neurotransmitters?
Chemical messengers that cause brain cells to turn on or off.
During an inpatient therapy group session, a client tells the members that he hears voices
that say his doctor is going to poison him. He continues, "I look around to see who's talking
to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found
out they were my imagination. The voices you hear aren't real either." Which
phenomenon, common to groups, is exemplified in this interchange?
Reality testing
What action should the nurse take when a client who is psychotic proposes goals that are
both unrealistic and undesirable?
Reflect the client's behavior and its consequences.
A female client who is admitted for treatment of uncontrolled diabetes mellitus is
withdrawn and tearful. She complains she has gained excessive weight because she hates
her diet, hates taking insulin, and just wants to be normal again. What therapeutic action
should the nurse take?
Inquire about emotional factors affecting the client's present condition.
A school-aged girl with severe birth defects and mental retardation is brought to the
emergency room because of a possible broken arm. The caregiver reports that the girl
sustained the injury when she fell from her wheelchair. Which intervention should the
nurse implement?
Evaluate the child for other injuries.
An adolescent female client is admitted to the Emergency Department because she reports
being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain
her vital signs, she begins screaming for her mother and curls up in the corner of the room.
What action should the nurse implement?
Reassign an all-female healthcare team to the client until her fear subsides
EXAM PREP WITH VERIFIED ANSWERS
At the end of a group therapy session, a client who is hospitalized for psychosis falls to the
floor when attempting to stand. What intervention should the nurse implement first?
Ask a group member to seek help.
Which nursing intervention should the nurse implement with parents who experience a
fetal demise and express the wish not to see the baby?
Keep the body available for a few hours in case they change their minds.
An adult female who is married and works full-time in a factory has been absent from
work for three days at a time on several occasions. Each time she returns to work, she
wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational
health nurse. What assessment question should the nurse use?
How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate
a referral to which healthcare team member?
Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care?
Focus on the client's positive or negative feelings toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch where
hair was lost from her scalp. She is accompanied by her husband who tells the nurse that
his wife caught her hair on the railing and pulled it out when she fell down the stairs. The
husband is solicitous of his wife and quickly answers questions on her behalf. He attempts
to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us
apart." What is the priority nursing intervention?
Require the husband to leave the cubicle while the client is being treated.
A female client with severe depression is given information about the risks, benefits,
alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the
informed consent for treatment. After the client's family leaves, the client tells the nurse, "I
signed the papers because my husband told me I will be deported if my depression is not
cured." What information should the nurse report to the healthcare provider?
The client's consent may have been coerced.
A male client with severe orthopedic injuries following a motor vehicle collision is irritable,
angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the
client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which
intervention is best for the nurse to implement?
Provide information about infection prevention.
The nurse is assessing a client with a history of borderline personality disorder. Which
question should the nurse include in the assessment?
Do you frequently have temper tantrums?
,During the admission of a male client to the mental health unit, the client tells the nurse
that he had a panic attack today and ran out of the physician's office. Which question is
most important for the nurse to ask this client?
Have you had any thoughts of hurting yourself?
The nurse completes an emergency admission of a male client with schizophrenia who has
not been taking his antipsychotic medications. The client is pacing, is extremely irritable,
and has a blood pressure of 146/96. What is the priority nursing action?
Reevaluate the client's blood pressure in an hour.
A young adult female client with panic disorder arrives in the Emergency Center with a 4-
day history of chest pain that began when her boyfriend left her. Initial assessment reveals
normal cardiopulmonary findings. Which information is most important for the nurse to
obtain?
Drugs taken in last 7 days.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells
the nurse, "There wasn't anything I could do to stop her drinking this morning." What
intervention should the nurse take at this time?
Tell the client that therapy cannot take place while she is intoxicated.
The nurse is planning care for a client with major depression who is admitted to the unit
after a recent suicide attempt. Which intervention has the highest priority for inclusion in
this client's plan of care?
Search the client's personal belongings.
A male client is brought to the emergency department by a police officer, who reports the
client was "disturbing the peace" by running naked in the street, striking out at others, and
smashing car windows. Which behaviors should the client demonstrate to determine if he
should be evaluated for involuntary commitment? (Choose all that apply.)
Threats to kill his friend, hears voices telling him to kill himself, reports he has not needed a bath
in 4 months and says he has not eaten in 3 days.
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and
motionless. What is the priority nursing problem?
High risk for fluid and electrolyte imbalance.
A client who had a miscarriage at 10-weeks gestation tells the nurse that she already
purchased some baby things and picked out a name. After the surgical dilation and
curettage (D&C), the client wants to go home as soon as possible. Based on the client's
statements, which action should the nurse implement?
Ask the client what name she had picked out for the infant.
A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal
again." How should the nurse respond?
"Tell me more about how things are with you."
A client is scheduled to complete a positron emission tomography (PET) scan. The client
asks the nurse to explain the reason the test was prescribed. How should the nurse
respond?
Results show activity in various portions of the brain.
Which technique is the most important therapeutic tool a nurse should use to provide
quality care to a psychiatric client?
Self-analysis
,A client with substance abuse is admitted to the mental health unit. Which action should be
implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)?
Collect a complete substance abuse history.
A female client with bipolar disorder, manic phase, is planning weekend activities with the
other clients on the unit. The client interrupts the group, insists that they change their
plans to a disco party, and begins to curse loudly when the group refuses to change the
plans. Which intervention should the nurse implement?
Escort the client to a quieter place
A client with a history of alcoholism is admitted with a compound fracture of the femur
after falling down the previous night. What additional assessment should be the priority
focus for the nurse?
Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.
The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago.
Which finding is most critical for the nurse to report to the healthcare provider?
Global confusion and inability to recognize family members.
A male client who is on the liver transplant list is called to the unit for a possible
transplant. When learning that the donor organ is no longer available, the client slams
doors and shouts vulgarities about his situation. What action should the nurse implement?
Express concern over his disappointment.
The nurse is caring for a female client who is admitted for depression with the nursing
diagnosis, "Self-esteem, chronic low." Which client response indicates to the nurse that the
client has improved self-esteem?
Identifies own strengths
A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will
always be this way and that there's no hope for me." What information should the nurse
provide?
Panic disorder is treatable in a number of different ways, including medication.
Which client outcome during hospitalization indicates improvement for a client who is
admitted with auditory hallucinations?
Tells when voices decrease.
Which action is most important for the nurse to implement during the initial interview for
a client who is admitted to the mental health unit?
Establish rapport in each phase of the nurse-client relationship.
Which statement made by an adolescent in group therapy should the nurse identify as a
priority in planning care?
I have a necktie in my room that I can use to hang myself.
A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is
released from the hospital. What action should the nurse implement?
Inform the healthcare provider and document the plan in the record.
Which client statement should the nurse identify as most typical of a client with mania?
I manage our finances great because I buy in big quantities.
A client is pacing in the hall near the nurses' station and swearing loudly. What response is
best for the nurse to provide?
You seem pretty upset. Tell me about it.
, A client actively involved in substance addiction therapy frequently relapses into
benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able
to kick this habit." How should the nurse respond?
The client must participate in making decisions about one's own physical and mental health.
Which action should the nurse implement during the termination phase of the nurse-client
relationship?
Help summarize accomplishments.
The daughter of an older male client tells the nurse that her father is becoming increasingly
forgetful. Which finding indicates that the client needs further evaluation of cognitive
function?
Cannot mentally retrace objects that were recently misplaced.
Which action should the nurse implement first for a client experiencing alcohol
withdrawal?
Prepare the environment to prevent self-injury.
The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT)
a half hour ago. Which action should the nurse implement first?
Monitor vital signs.
The client with depression asks the nurse, " What are neurotransmitters? My doctor thinks
my problem may lie with the neurotransmitters in my brain." What information should the
nurse use to support an explanation of neurotransmitters?
Chemical messengers that cause brain cells to turn on or off.
During an inpatient therapy group session, a client tells the members that he hears voices
that say his doctor is going to poison him. He continues, "I look around to see who's talking
to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found
out they were my imagination. The voices you hear aren't real either." Which
phenomenon, common to groups, is exemplified in this interchange?
Reality testing
What action should the nurse take when a client who is psychotic proposes goals that are
both unrealistic and undesirable?
Reflect the client's behavior and its consequences.
A female client who is admitted for treatment of uncontrolled diabetes mellitus is
withdrawn and tearful. She complains she has gained excessive weight because she hates
her diet, hates taking insulin, and just wants to be normal again. What therapeutic action
should the nurse take?
Inquire about emotional factors affecting the client's present condition.
A school-aged girl with severe birth defects and mental retardation is brought to the
emergency room because of a possible broken arm. The caregiver reports that the girl
sustained the injury when she fell from her wheelchair. Which intervention should the
nurse implement?
Evaluate the child for other injuries.
An adolescent female client is admitted to the Emergency Department because she reports
being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain
her vital signs, she begins screaming for her mother and curls up in the corner of the room.
What action should the nurse implement?
Reassign an all-female healthcare team to the client until her fear subsides
