nurs 360 final exam 2 fall 2024 Questions With Complete
Solutions
A 14-year-old client has just been admitted to the psychiatric
unit for anorexia nervosa. She is emaciated and refuses to eat.
What is the priority nursing diagnosis for this client?
a. Complicated grieving
b. Imbalanced nutrition: Less than body requirements.
c. Interrupted family processes
d. Anxiety (severe) Correct Answer b. Imbalanced nutrition:
Less than body requirements.
A battered woman presents to the emergency department with
multiple cuts and abrasions. Her right eye is swollen shut. She
says that her husband did this to her. What is the priority nursing
intervention?
a. Tending to the immediate care of her wounds
b. Providing her with information about a safe place to stay
c. Administering the prn tranquilizer ordered by the physician
d. Explaining how she may go about bringing charges against
her husband Correct Answer a. Tending to the immediate care
of her wounds
A child aged 5, is sent to the school nurse's office with an upset
stomach, she has vomited and soiled her blouse. when the nurse
removes her blouse, she notices that the child has numerous
bruises on her arms and torso in various stages of healing. She
also notices some small scars, and her abdomen protrudes from
her small thin frame. From the objective physical assessment,
the nurse should search further for:
a. Physical and sexual abuse.
,b. Physical abuse and neglect.
c. Emotional neglect.
d. Sexual and emotional abuse. Correct Answer b. Physical
abuse and neglect.
A child with ADHD is admitted to a residential treatment
program. Which of the following group activities would be most
appropriate for the nurse to recommend?
a. Monopoly
b. Volleyball
c. Pool
d. Checkers Correct Answer b. Volleyball
A client admitted to the emergency department smells strongly
of alcohol, and his wife reports he has been a heavy drinker for
the last 25 years. After the nurse completes an assessment, the
physician asks if there are any physical signs of long-term
chronic alcohol abuse. Which of these findings should the nurse
include in reporting to the physician? (Select all that apply.)
a. The client reports weak leg muscles, and his gait is unsteady.
b. The client's abdomen is distended.
c. The client reports he was coughing up some blood.
d. The client reports he has double vision.
e. Blood tests reveal a low white blood cell count Correct
Answer a. The client reports weak leg muscles, and his gait is
unsteady.
b. The client's abdomen is distended.
c. The client reports he was coughing up some blood.
d. The client reports he has double vision.
e. Blood tests reveal a low white blood cell count
,A client admitted to the inpatient detoxification program for
alcohol withdrawal approaches the nurse complaining of nausea
and feeling shaky. The nurse notices that the client has hand
tremors and appears diaphoretic. Which of these nursing
interventions is a priority?
a. Check the client's temperature.
b. Send a urine sample to the laboratory for a random drug
screen.
c. Ask the client if there is anything that he is particularly
stressed about.
d. Administer prn benzodiazepine that was ordered for
management of withdrawal symptoms. Correct Answer d.
Administer prn benzodiazepine that was ordered for
management of withdrawal symptoms.
A client admitted to the inpatient psychiatric unit with bipolar
disorder tells the nurse, "I need to sit in on change-of-shift report
because I have been appointed director of this unit." Which
action by the nurse demonstrates the best clinical judgment at
this point?
a. Invite the client to sit in on the change-of-shift report, but do
not share any confidential client information.
b. Instruct the client that this is not permitted and redirect the
client to other unit activities that are available.
c. Tell the client that she is delusional but that these symptoms
will go away with medication.
d. Place the client in seclusion for protection of self and others.
Correct Answer b. Instruct the client that this is not permitted
and redirect the client to other unit activities that are available.
, A client and his girlfriend had an argument during her visit to
the psychiatric unit. Which behavior by the client would indicate
he is learning to adaptively problem-solve his frustrations?
a. The client requests to be put in restraints to prevent hurting
his girlfriend.
b. When his girlfriend leaves, the client goes to the exercise
room to try to release his anger with physical activity.
c. The client says to the nurse, "I guess I'm going to have to
dump that broad!"
d. The client says to his girlfriend, "You'd better leave before I
do something I'm sorry for." Correct Answer b. When his
girlfriend leaves, the client goes to the exercise room to try to
release his anger with physical activity.
A client arrives at the emergency department and tells the nurse
her husband inflicted the cuts to her face that required sutures.
She says, "I didn't want to come. I'm really okay. He only does
this when he has too much to drink. I just shouldn't have yelled
at him." The best response by the nurse is:
a. "How often does he drink too much?"
b. "It is not your fault. You did the right thing by coming here."
c. "How many times has he done this to you?"
d. "He is not a good husband. You have to leave him before he
kills you." Correct Answer b. "It is not your fault. You did the
right thing by coming here."
A client comes into the emergency department stating that he is
"crashing" and feels like he'd "be better off dead." Which of
these nursing interventions is a priority?
a. Instruct the client not to worry; these are temporary signs of
withdrawal and should go away in a few days.
Solutions
A 14-year-old client has just been admitted to the psychiatric
unit for anorexia nervosa. She is emaciated and refuses to eat.
What is the priority nursing diagnosis for this client?
a. Complicated grieving
b. Imbalanced nutrition: Less than body requirements.
c. Interrupted family processes
d. Anxiety (severe) Correct Answer b. Imbalanced nutrition:
Less than body requirements.
A battered woman presents to the emergency department with
multiple cuts and abrasions. Her right eye is swollen shut. She
says that her husband did this to her. What is the priority nursing
intervention?
a. Tending to the immediate care of her wounds
b. Providing her with information about a safe place to stay
c. Administering the prn tranquilizer ordered by the physician
d. Explaining how she may go about bringing charges against
her husband Correct Answer a. Tending to the immediate care
of her wounds
A child aged 5, is sent to the school nurse's office with an upset
stomach, she has vomited and soiled her blouse. when the nurse
removes her blouse, she notices that the child has numerous
bruises on her arms and torso in various stages of healing. She
also notices some small scars, and her abdomen protrudes from
her small thin frame. From the objective physical assessment,
the nurse should search further for:
a. Physical and sexual abuse.
,b. Physical abuse and neglect.
c. Emotional neglect.
d. Sexual and emotional abuse. Correct Answer b. Physical
abuse and neglect.
A child with ADHD is admitted to a residential treatment
program. Which of the following group activities would be most
appropriate for the nurse to recommend?
a. Monopoly
b. Volleyball
c. Pool
d. Checkers Correct Answer b. Volleyball
A client admitted to the emergency department smells strongly
of alcohol, and his wife reports he has been a heavy drinker for
the last 25 years. After the nurse completes an assessment, the
physician asks if there are any physical signs of long-term
chronic alcohol abuse. Which of these findings should the nurse
include in reporting to the physician? (Select all that apply.)
a. The client reports weak leg muscles, and his gait is unsteady.
b. The client's abdomen is distended.
c. The client reports he was coughing up some blood.
d. The client reports he has double vision.
e. Blood tests reveal a low white blood cell count Correct
Answer a. The client reports weak leg muscles, and his gait is
unsteady.
b. The client's abdomen is distended.
c. The client reports he was coughing up some blood.
d. The client reports he has double vision.
e. Blood tests reveal a low white blood cell count
,A client admitted to the inpatient detoxification program for
alcohol withdrawal approaches the nurse complaining of nausea
and feeling shaky. The nurse notices that the client has hand
tremors and appears diaphoretic. Which of these nursing
interventions is a priority?
a. Check the client's temperature.
b. Send a urine sample to the laboratory for a random drug
screen.
c. Ask the client if there is anything that he is particularly
stressed about.
d. Administer prn benzodiazepine that was ordered for
management of withdrawal symptoms. Correct Answer d.
Administer prn benzodiazepine that was ordered for
management of withdrawal symptoms.
A client admitted to the inpatient psychiatric unit with bipolar
disorder tells the nurse, "I need to sit in on change-of-shift report
because I have been appointed director of this unit." Which
action by the nurse demonstrates the best clinical judgment at
this point?
a. Invite the client to sit in on the change-of-shift report, but do
not share any confidential client information.
b. Instruct the client that this is not permitted and redirect the
client to other unit activities that are available.
c. Tell the client that she is delusional but that these symptoms
will go away with medication.
d. Place the client in seclusion for protection of self and others.
Correct Answer b. Instruct the client that this is not permitted
and redirect the client to other unit activities that are available.
, A client and his girlfriend had an argument during her visit to
the psychiatric unit. Which behavior by the client would indicate
he is learning to adaptively problem-solve his frustrations?
a. The client requests to be put in restraints to prevent hurting
his girlfriend.
b. When his girlfriend leaves, the client goes to the exercise
room to try to release his anger with physical activity.
c. The client says to the nurse, "I guess I'm going to have to
dump that broad!"
d. The client says to his girlfriend, "You'd better leave before I
do something I'm sorry for." Correct Answer b. When his
girlfriend leaves, the client goes to the exercise room to try to
release his anger with physical activity.
A client arrives at the emergency department and tells the nurse
her husband inflicted the cuts to her face that required sutures.
She says, "I didn't want to come. I'm really okay. He only does
this when he has too much to drink. I just shouldn't have yelled
at him." The best response by the nurse is:
a. "How often does he drink too much?"
b. "It is not your fault. You did the right thing by coming here."
c. "How many times has he done this to you?"
d. "He is not a good husband. You have to leave him before he
kills you." Correct Answer b. "It is not your fault. You did the
right thing by coming here."
A client comes into the emergency department stating that he is
"crashing" and feels like he'd "be better off dead." Which of
these nursing interventions is a priority?
a. Instruct the client not to worry; these are temporary signs of
withdrawal and should go away in a few days.
