QUESTIONS AND VERIFIED
ANSWERS 2024
1. A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the
mental health unit. The client is confused and disoriented. When developing a plan of
care, which of the following would be the priority intervention for this client?
Select one:
a. Stabilize the client's psychiatric needs.
b. Accept and make the client feel safe.
c. Explain unit rules to the client.
d. Orient the client to the unit.: B.
Stabilizing the client's psychiatric needs with therapy and medications will take some
time, and therefore this is not the priority.
2. A client diagnosed with schizophrenia and experiencing frequent auditory hallucinations
is admitted to an inpatient psychiatric unit. Which of the following would be the most
effective, initial strategy for the nurse to implement?
Select one: a.
Agree with the client that the voices are audible.
,b. Ask the client to rest in a quiet area until the voices are gone. c. Ask the
client to describe the components of the hallucination.
d.Explain to the client that the hallucination is not real.: Ask the client to
describe the components of the hallucination.
Do not attempt to convince the client that the hallucination is not real because it is real to
the client. Do not argue with the client or respond directly to the voices.
3. A nurse is caring for an adolescent client who is recovering from a traumatic below the
knee amputation. The day after surgery, the client refuses to look at or touch the affected
leg. Which of the following nursing interventions would be most beneficial to this client?
Select one: a.
Gently examine and redress the stump without frowning or grimacing.
b. Insist that the client participate in bathing and examining his affected leg.
c. Avoid discussing the amputation until the client initiates conversation.
d. Remind the client that full mobility is possible once fitted for a prosthesis.: A.
This client is exhibiting avoidance behaviors which are expected with a sudden body image
change and should resolve over a period of a few days. It is inappropriate to insist that the
client participates in seeing and touching the leg affected leg, especially the first day after
surgery.
4. A nurse is caring for an adolescent client admitted to the nursing unit three days ago.
The client is withdrawn, unwilling to eat, and does not interact with the staff. The nurse
correctly understands which of the following would provide the best support for this
client?
, a. An opportunity to view a popular DVD.
b. A call from the client's sibling. c.
c. A visit with a parent.
d. A visit with friends from school.: d.
A popular DVD may be entertaining and distracting for the adolescent, but will not
provide support. A better choice would be to encourage the adolescent to phone a
friend.
5. During a group therapy session on a psychiatric unit, the nurse leader observes that
one of the clients frequently interrupts the session. Which of the following nursing
actions is the most appropriate for this situation?
Select one: a.
Ask the client to speak privately with a nurse after the meeting. b.
Discuss this observation during the post-meeting evaluation. c.
Encourage another group member to reprimand the client. d.
Tell the client that the interrupting behavior must be discontinued.: Ask the client to speak
privately with a nurse after the meeting.
A therapeutic milieu group aims to help increase self-esteem, decrease social isolation,
encourage appropriate social behaviors, and educate clients in basic living skills.
Confronting the client during the meeting could negatively affect self-esteem and increase
social isolation. The behavior needs to be addressed, but not in an openly confrontational
way.