NU 334 Final Exam With
Complete Solution
A client experienced PTSD after a significant assault and has been
hospitalized for nearly a week. He states to the nurse, "I'm thinking of ending
it all." Which statement by the nurse would be the most effective? - ANSWER
"You must be feeling very sad right now"
A client with psychotic symptoms is in an inpatient psychiatric unit. He
states, "Can't you hear him? It's the devil. He's telling me I'm going to hell."
Which nursing reply would be most helpful to Larry? - ANSWER "The voices
you are hearing sound scary. I don't hear any voices speaking. Can you try
and focus on my voice?"
Which of the following would indicate that a client is experiencing delusions?
- ANSWER "I think I was implanted with a computer chip by the doctor when
I slept last night."
A client with schizophrenia has been maintained on Haldol for one year. At
his 12 month follow-up appointment at the Mental Health outpatient clinic,
his nurse noticed a twitch on the right side of his face and unusual tongue
movements. Which nursing intervention takes priority? - ANSWER Hold the
Haldol and let the doctor know of a suspicion of tardive dyskinesia
A 35 year old female client is diagnosed with conversion disorder. She
demonstrates paralysis of the legs. What is the best nursing intervention for
the nurse to utilize? - ANSWER Avoid focusing on the client's physical
limitations
,A female patient continuously presents to the ED with physical complaints.
The complaints range from lower right quadrant pain, nervousness, back
pain, chest pain, foot pain, and a diffuse headache. All physiological tests
have come out negative. The client has been diagnosed with anxiety disorder.
Which short term goal would be realistic? - ANSWER The patient will
participate in group therapy to discuss her illnesses
A client diagnosed with a schizoid personality disorder chooses solitary
activities, lacks close friends, and appears indifferent to criticism. Which
nursing diagnosis would be appropriate for this client's problems? - ANSWER
Social isolation related to discomfort with human interactions as evidenced
by avoiding others
A client diagnosed with PTSD is experiencing a flashback. Which intervention
takes priority? - ANSWER Stay with the patient during the flashback
A client is being treated by a nurse therapist for an adjustment disorder. Her
psychiatric diagnosis is adjustment disorder with depressed mood following
the loss of her closest friend. Which of the following is true regarding the
diagnosis of adjustment disorder? - ANSWER A client's adjustment disorder
may have been influenced by past experiences, previous dysfunctional grief,
or constitutional factors
A client recently prescribed Seroquel, an antipsychotic, complains to the
nurse of severe muscle spasms. On examination, heart rate is 110, blood
pressure is 160/92 mmHg, and temperature is 102.5 degrees. The should
should: - ANSWER Immediately report findings as he/she suspects
neuroleptic malignant syndrome
A client was recently diagnosed with persistent depressive disorder. Her
therapist utilizes techniques primarily consistent with the cognitive therapy
, model. The goal of cognitive therapy with depressed clients is to: - ANSWER
Identify and change dysfunctional patterns of thinking
A nurse assesses a client suspected of having major depressive disorder.
Which client symptom would eliminate this diagnosis? - ANSWER The client
has maxed-out charge cards and exhibits promiscuous behavior
A nurse teaches a group of community health colleagues about the use of
naltrexone in treating alcoholism. The nurse interprets that the teaching was
effective if the colleagues state that the naltrexone is used to do which of the
following? - ANSWER Reduces the craving for alcohol
A nurse works with a client who begins to escalate in anger. Which risk factor
would the nurse recognize as the most reliable indicator of potential client
violence? - ANSWER History of a assaultive behavior
A client diagnosed with antisocial personality disorder spits, curses, and
refuses to answer assessment questions. He believes that he was wrongfully
admitted. Which is the most appropriate nursing statement to address this
behavior? - ANSWER "I understand that you are angry, but this behavior will
not be tolerated"
During the initial interview with a patient, the nurse begins to feel
uncomfortable and realizes that the patient's behaviors and mannerisms
remind the nurse of the nurse's abusive parent. The nurse concludes that the
current situation represents which phenomenon? - ANSWER
Countertransference
A female presents in the ED with multiple contusions and a broken wrist. She
tells the nurse that her husband hit her, stating "It's ok though. He
apologized and I believe that he can change." Which phase does this
Complete Solution
A client experienced PTSD after a significant assault and has been
hospitalized for nearly a week. He states to the nurse, "I'm thinking of ending
it all." Which statement by the nurse would be the most effective? - ANSWER
"You must be feeling very sad right now"
A client with psychotic symptoms is in an inpatient psychiatric unit. He
states, "Can't you hear him? It's the devil. He's telling me I'm going to hell."
Which nursing reply would be most helpful to Larry? - ANSWER "The voices
you are hearing sound scary. I don't hear any voices speaking. Can you try
and focus on my voice?"
Which of the following would indicate that a client is experiencing delusions?
- ANSWER "I think I was implanted with a computer chip by the doctor when
I slept last night."
A client with schizophrenia has been maintained on Haldol for one year. At
his 12 month follow-up appointment at the Mental Health outpatient clinic,
his nurse noticed a twitch on the right side of his face and unusual tongue
movements. Which nursing intervention takes priority? - ANSWER Hold the
Haldol and let the doctor know of a suspicion of tardive dyskinesia
A 35 year old female client is diagnosed with conversion disorder. She
demonstrates paralysis of the legs. What is the best nursing intervention for
the nurse to utilize? - ANSWER Avoid focusing on the client's physical
limitations
,A female patient continuously presents to the ED with physical complaints.
The complaints range from lower right quadrant pain, nervousness, back
pain, chest pain, foot pain, and a diffuse headache. All physiological tests
have come out negative. The client has been diagnosed with anxiety disorder.
Which short term goal would be realistic? - ANSWER The patient will
participate in group therapy to discuss her illnesses
A client diagnosed with a schizoid personality disorder chooses solitary
activities, lacks close friends, and appears indifferent to criticism. Which
nursing diagnosis would be appropriate for this client's problems? - ANSWER
Social isolation related to discomfort with human interactions as evidenced
by avoiding others
A client diagnosed with PTSD is experiencing a flashback. Which intervention
takes priority? - ANSWER Stay with the patient during the flashback
A client is being treated by a nurse therapist for an adjustment disorder. Her
psychiatric diagnosis is adjustment disorder with depressed mood following
the loss of her closest friend. Which of the following is true regarding the
diagnosis of adjustment disorder? - ANSWER A client's adjustment disorder
may have been influenced by past experiences, previous dysfunctional grief,
or constitutional factors
A client recently prescribed Seroquel, an antipsychotic, complains to the
nurse of severe muscle spasms. On examination, heart rate is 110, blood
pressure is 160/92 mmHg, and temperature is 102.5 degrees. The should
should: - ANSWER Immediately report findings as he/she suspects
neuroleptic malignant syndrome
A client was recently diagnosed with persistent depressive disorder. Her
therapist utilizes techniques primarily consistent with the cognitive therapy
, model. The goal of cognitive therapy with depressed clients is to: - ANSWER
Identify and change dysfunctional patterns of thinking
A nurse assesses a client suspected of having major depressive disorder.
Which client symptom would eliminate this diagnosis? - ANSWER The client
has maxed-out charge cards and exhibits promiscuous behavior
A nurse teaches a group of community health colleagues about the use of
naltrexone in treating alcoholism. The nurse interprets that the teaching was
effective if the colleagues state that the naltrexone is used to do which of the
following? - ANSWER Reduces the craving for alcohol
A nurse works with a client who begins to escalate in anger. Which risk factor
would the nurse recognize as the most reliable indicator of potential client
violence? - ANSWER History of a assaultive behavior
A client diagnosed with antisocial personality disorder spits, curses, and
refuses to answer assessment questions. He believes that he was wrongfully
admitted. Which is the most appropriate nursing statement to address this
behavior? - ANSWER "I understand that you are angry, but this behavior will
not be tolerated"
During the initial interview with a patient, the nurse begins to feel
uncomfortable and realizes that the patient's behaviors and mannerisms
remind the nurse of the nurse's abusive parent. The nurse concludes that the
current situation represents which phenomenon? - ANSWER
Countertransference
A female presents in the ED with multiple contusions and a broken wrist. She
tells the nurse that her husband hit her, stating "It's ok though. He
apologized and I believe that he can change." Which phase does this
