Correct Answers
The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which intervention
would be included in the plan of care? Select all that apply.
1. Allow client to remain on current laxatives
2. Assess the client for electrolyte imbalances
3. Be alert to hidden or discarded food wrapper
4. Do not allow client to keep a food diary during hospitalization
5. Monitor the client for 1-2 hours after each meal in a central area - Correct Answer: 2. Assess the client
for electrolyte imbalances
3. Be alert to hidden or discarded food wrapper
5. Monitor the client for 1-2 hours after each meal in a central area
A new client at the sleep disorders clinical tells the nurse, "I have not slept well in a year, so I never feel
good. I do not expect things will ever improve or be any different." Which of the following interventions
should the nurse consider for this client?
1. Suggest the use of alcohol as a sedative to promote sleep
2. Provide instruction on relaxation techniques
3. Teach fatigue producing exercises for the client to become overtired
4. Encourage long daytime naps to compensate for the sleep deprivation - Correct Answer: 2. Provide
instruction on relaxation techniques
Which nursing action should occur first regarding a client who has a problem of sexual dysfunction or
sexual disorder?
1. The nurse should develop an understanding of human sexual response
2. The nurse should assess the client's sexual functioning and needs
3. The nurse should acquire knowledge of the client's sexual roles
4. The nurse should clarify own personal values about sexuality - Correct Answer: 4. The nurse should
clarify own personal values about sexuality
,A client diagnosed with schizophrenia has been taking chlorpromazine daily for several weeks. The nurse
observes that the client's head and neck are contracted and the client's eyes are locked in an upward
position. Which of the following is the nurse's best analysis and action?
1. The client has tardive dyskinesia. The nurse should teach the client relaxation exercises.
2. The client is having an acute dystonic reaction. The nurse should administer benztropine IM per PRN
order.
3. The client has akathisia. The nurse should notify the psychiatrist to discuss a possible change in
medication.
4. The client is experiencing auditory hallucinations. The nurse should administer haloperidol PO per PRN
order. - Correct Answer: 2. The client is having an acute dystonic reaction. The nurse should administer
benztropine IM per PRN order.
A client diagnosed with borderline personality disorder and chronic back pain takes the maximum safe
dose of opioid analgesic medication. The client tells the nurse, "The other nurses don't care about my
pain, but you've always been so good to me. Could you give me a little extra medication? I won't tell
anyone." Which of the following is the nurse's best response?
1. "I'll check with your doctor and get back to you."
2. "I'm sorry. I wish there was something more we could do to help you."
3. "No. I think you're trying to manipulate me into giving you more medication."
4. "I understand that you are in pain, but giving you more medication would not be safe." - Correct
Answer: 4. "I understand that you are in pain, but giving you more medication would not be safe."
The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to
monitor the client's behavior?
1. During 1-2 hours after each meal
2. During every meal
3. During the evening meal
4. During the overnight hours - Correct Answer: 1. During 1-2 hours after each meal
A client tells the nurse, "Everyone says we should sleep 8 hours a night. I can only sleep 6 hours no
matter how hard I try. Am I doing harm to my body?" Which of the following would be the most
appropriate response by the nurse?
1. Tell me about strategies you have tried to increase your total sleep hours
, 2. Lack of sleep acts as a stressor on the body and can cause physical changes
3. If you have really tried to sleep more, maybe you should consult your healthcare provider
4. If you function well with 6 hours of sleep, you are a short sleeper. That's normal for some people -
Correct Answer: 4. If you function well with 6 hours of sleep, you are a short sleeper. That's normal for
some people
A man who frequently experiences premature ejaculation tells the nurse, "I feel like such a failure. It's so
awful for both me and my partner." Which of the following would be the most appropriate therapeutic
response by the nurse?
1. I sense you are feeling frustrated and upset
2. Tell me more about feeling like a failure
3. You are too hard on yourself
4. What do you mean by awful? - Correct Answer: 1. I sense you are feeling frustrated and upset
A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to
the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best
response by the nurse?
1. Do you need something to help you calm down?
2. Don't pay any attention to the voices. Let's go into the dayroom.
3. The voices are not real. Tell them to go away.
4. What are the voices saying to you? - Correct Answer: 1. Do you need something to help you calm
down?
A nurse appropriately set limits while interacting with a client diagnosed with a borderline personality
disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can
see I was wrong. You're the worst nurse ever." Which defense mechanism is being used by this client?
1. Splitting
2. Projection
3. Displacement
4. Reaction formation - Correct Answer: 1. Splitting
Chapter 18 Evolve