NSG 3450 Exam 2
A female nurse had been sexually assaulted as a teenager. she finds it difficult to work w/ pt's who have
undergone the same trauma. What is the most helpful response?
a. discussing these feelings w. the nurse supervisor
b. requesting that these pt's not be a part of her assignment
c. discussing these feelings w/ a mental health professional
d. accepting her role in providing unbiased, respectful, and professional care to all pt's - ANSWER-C.
discussing these feelings w/ a mental health professional
a homebound pt diagnosed w/ agoraphobia has been receiving therapy in the home. the nurse
evaluated pt teaching is effective when the pt states:
a. "I may never leave the house again."
b. "having groceries delivered is very convenient"
c. "my risk for agoraphobia is increased by my family history"
d. "I will go out again, someday, just not today" - ANSWER-C. "my risk for agoraphobia is increased by
my family history"
A nurse assess a pt w/ a tentative diagnosis of Generalized Anxiety Disorder. Which question would be
most appropriate for the nurse to ask?
a. "have you been a victim of a crime or seen someone badly injured or killed?"
b. "do you feel especially uncomfortable in social situations involving people?"
c. "do you repeatedly do certain things over and over again?"
d. "do you find it difficult to control your worrying?" - ANSWER-D. "do you find it difficult to control your
worrying?" (rationale: GAD is defined as "Excessive worrying and anxiety")
A nurse wants to teach alternative coping strategies to a pt experiencing severe anxiety. Which action
should Nurse perform first?
a. verify pt.'s learning style
b. lower pt's current anxiety
c. create outcomes and a teaching plan
d. assess how the pt uses defense mechanisms - ANSWER-B. lower the pt's current anxiety
A person has minor physical injuries after an auto accident. The person is unable to focus, and says, "I
feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and
hyperventilation. What is this person's level of anxiety?
a. mild
b. moderate
,NSG 3450 Exam 2
c. severe
d. panic - ANSWER-C. severe
A pregnant woman is in a relationship w/ a male who routinely abuses her. Her unborn child may
engage in high-risk behavior as a tees as a result of:
a. maternal stress
b. parental nurturing
c. appropriate stress responses in the brain
d. memories of the abuse - ANSWER-A. maternal stress
A pt experiencing moderate anxiety says "I feel undone." An appropriate response for the nurse would
be:
a. "what would you like me to do to help you?"
b. Why do you suppose you are feeling anxious?"
c. "I'm not sure I understand. Give me an example."
d. "You must get your feelings under control before we can continue" - ANSWER-c. "I'm not sure I
understand. Give me an example."
A pt experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's
best action.
a. ask, "I'm not sure what you mean. Give me an example."
b. capture the pt in a basket-hold to increase feelings of control
c. tell the pt "Stop running and take a deep breath. I will help you."
d. assemble several staff members and say, "we will take you to seclusion to help you regain control" -
ANSWER-C. tell the pt "Stop running and take a deep breath. I will help you."
a pt fearfully runs from chair to chair crying, "They're coming! They're coming!" The pt does not follow
the staff's directions or responses to verbal interventions. The initial nursing intervention of highest
priority is to:
a. provide for pt's safety
b. encourage clarification of feelings
c. respect pt's personal space
d. offer an outlet for the pt's energy - ANSWER-A. provide for the pt's safety
a pt fearfully runs from chair to chair crying, "They're coming! They're coming!" The pt does not follow
the staff's directions or responses to verbal interventions. Which nursing diagnosis has the highest
priority?
, NSG 3450 Exam 2
a. fear
b. risk for injury
c. self-care deficit
d. disturbed thought processes - ANSWER-B. Risk for injury
A pt is experiencing moderate anxiety. The nurse encourages the pt to talk about feelings and concerns.
What is the rationale for this intervention?
a. offering hope allays and defuses the pt's anxiety
b. concerns stated aloud become less overwhelming and help problem solving begin
c. anxiety is reduced by focusing on and validating what is occurring in the environment
d. encouraging pt's to explore alternatives increases the sense of controls and lessens anxiety -
ANSWER-B. concerns stated aloud become less overwhelming and help problem solving begin
a pt undergoing a diagnostic test says, "nothing is wrong w/ me except a stubborn chest cold." The
spouse reports the pt smokes, coughs daily, lost 15 lbs, and is easily fatigued. Which defense mechanism
is the pt using?
a. displacement
b. regression
c. projection
d. denial - ANSWER-D. denial
A pt w/ an abdominal mass is scheduled for a biopsy. The pt has difficulty understanding the nurse's
comments and asks, "What do you mean? What are they going to do?" Assessment findings include
tremulous voice, respirations 28, and pulse 110. What is the pt's level of anxiety?
a. mild
b. moderate
c. severe
d. panic - ANSWER-B. moderate (rationale: the pt has "difficulty understanding")
A pt whose history included experiences w/ abusive partners is being treated for major depressive
disorder. The pt's care plan includes "rape-trauma syndrome" among its nursing diagnosis. What goal is
directly associated w/ this diagnosis?
a. remains free from self-harm
b. wears appropriate clothing
c. reports feeling strong and having a self of hopefulness
A female nurse had been sexually assaulted as a teenager. she finds it difficult to work w/ pt's who have
undergone the same trauma. What is the most helpful response?
a. discussing these feelings w. the nurse supervisor
b. requesting that these pt's not be a part of her assignment
c. discussing these feelings w/ a mental health professional
d. accepting her role in providing unbiased, respectful, and professional care to all pt's - ANSWER-C.
discussing these feelings w/ a mental health professional
a homebound pt diagnosed w/ agoraphobia has been receiving therapy in the home. the nurse
evaluated pt teaching is effective when the pt states:
a. "I may never leave the house again."
b. "having groceries delivered is very convenient"
c. "my risk for agoraphobia is increased by my family history"
d. "I will go out again, someday, just not today" - ANSWER-C. "my risk for agoraphobia is increased by
my family history"
A nurse assess a pt w/ a tentative diagnosis of Generalized Anxiety Disorder. Which question would be
most appropriate for the nurse to ask?
a. "have you been a victim of a crime or seen someone badly injured or killed?"
b. "do you feel especially uncomfortable in social situations involving people?"
c. "do you repeatedly do certain things over and over again?"
d. "do you find it difficult to control your worrying?" - ANSWER-D. "do you find it difficult to control your
worrying?" (rationale: GAD is defined as "Excessive worrying and anxiety")
A nurse wants to teach alternative coping strategies to a pt experiencing severe anxiety. Which action
should Nurse perform first?
a. verify pt.'s learning style
b. lower pt's current anxiety
c. create outcomes and a teaching plan
d. assess how the pt uses defense mechanisms - ANSWER-B. lower the pt's current anxiety
A person has minor physical injuries after an auto accident. The person is unable to focus, and says, "I
feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and
hyperventilation. What is this person's level of anxiety?
a. mild
b. moderate
,NSG 3450 Exam 2
c. severe
d. panic - ANSWER-C. severe
A pregnant woman is in a relationship w/ a male who routinely abuses her. Her unborn child may
engage in high-risk behavior as a tees as a result of:
a. maternal stress
b. parental nurturing
c. appropriate stress responses in the brain
d. memories of the abuse - ANSWER-A. maternal stress
A pt experiencing moderate anxiety says "I feel undone." An appropriate response for the nurse would
be:
a. "what would you like me to do to help you?"
b. Why do you suppose you are feeling anxious?"
c. "I'm not sure I understand. Give me an example."
d. "You must get your feelings under control before we can continue" - ANSWER-c. "I'm not sure I
understand. Give me an example."
A pt experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's
best action.
a. ask, "I'm not sure what you mean. Give me an example."
b. capture the pt in a basket-hold to increase feelings of control
c. tell the pt "Stop running and take a deep breath. I will help you."
d. assemble several staff members and say, "we will take you to seclusion to help you regain control" -
ANSWER-C. tell the pt "Stop running and take a deep breath. I will help you."
a pt fearfully runs from chair to chair crying, "They're coming! They're coming!" The pt does not follow
the staff's directions or responses to verbal interventions. The initial nursing intervention of highest
priority is to:
a. provide for pt's safety
b. encourage clarification of feelings
c. respect pt's personal space
d. offer an outlet for the pt's energy - ANSWER-A. provide for the pt's safety
a pt fearfully runs from chair to chair crying, "They're coming! They're coming!" The pt does not follow
the staff's directions or responses to verbal interventions. Which nursing diagnosis has the highest
priority?
, NSG 3450 Exam 2
a. fear
b. risk for injury
c. self-care deficit
d. disturbed thought processes - ANSWER-B. Risk for injury
A pt is experiencing moderate anxiety. The nurse encourages the pt to talk about feelings and concerns.
What is the rationale for this intervention?
a. offering hope allays and defuses the pt's anxiety
b. concerns stated aloud become less overwhelming and help problem solving begin
c. anxiety is reduced by focusing on and validating what is occurring in the environment
d. encouraging pt's to explore alternatives increases the sense of controls and lessens anxiety -
ANSWER-B. concerns stated aloud become less overwhelming and help problem solving begin
a pt undergoing a diagnostic test says, "nothing is wrong w/ me except a stubborn chest cold." The
spouse reports the pt smokes, coughs daily, lost 15 lbs, and is easily fatigued. Which defense mechanism
is the pt using?
a. displacement
b. regression
c. projection
d. denial - ANSWER-D. denial
A pt w/ an abdominal mass is scheduled for a biopsy. The pt has difficulty understanding the nurse's
comments and asks, "What do you mean? What are they going to do?" Assessment findings include
tremulous voice, respirations 28, and pulse 110. What is the pt's level of anxiety?
a. mild
b. moderate
c. severe
d. panic - ANSWER-B. moderate (rationale: the pt has "difficulty understanding")
A pt whose history included experiences w/ abusive partners is being treated for major depressive
disorder. The pt's care plan includes "rape-trauma syndrome" among its nursing diagnosis. What goal is
directly associated w/ this diagnosis?
a. remains free from self-harm
b. wears appropriate clothing
c. reports feeling strong and having a self of hopefulness
