Proctored Comprehensive Assessment Form A: Certified
for High Academic Standards, Chosen from Top
Universities
A nurse in a emergency department is assessing a client for suspected cocaine
intoxication. Which of the following findings should the nurse expect? a.
Nystagmus
b. Dilated pupils
c. Hypersomnia
d. Depression - -correct ans- -b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic
nervous system.
A nurse enters the room of a client who becomes verbally abusive. Which of the following
actions should the nurse take?
a. Inform the client of consequences.
b. Speak slowly in a low, calm voice.
c. Forbid the client from speaking in an abusive manner.
d. Remain a distance of 1 ft away from the client. - -correct ans- -b. Speak slowly in a low, calm
voice.
Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and
caring.
A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no
idea what I am going to do. I cannot think right now." Which of the following actions should the
nurse take?
,a. Identify other housing options and sources of transportation.
b. Notify the facility chaplain to request scheduling an appointment.
c. Confirm that everything will be alright because belongings can be replaced.
d. Maintain eye contact with client and summarize the client's feeings. - -correct ans- -d.
Maintain eye contact with the client and summarize the client's feelings.
This demonstrates therapeutic communication. During the initial interview, it is important for
the nurse to provide an atmosphere of support and safety. If a person believes that the
someone is genuinely concerned, then he may believe that help is available. Maintaining eye
contact demonstrates support, empathy, and advocacy.
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should
the nurse recommend for group therapy?
a. A client who has been taking amitriptyline for 3 months for depression.
b. A client exhibiting psychotic behavior.
c. A client admitted 12 hr ago for acute mania.
d. A client who is experiencing alcohol intoxication. - -correct ans- -a. A client who has been
taking amitriptyline for 3 months for depression.
Psychotherapy groups provide clients with the opportunity to enhance their personal
relationships, increase self-awareness and try new behaviors in a safe social setting.
Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be
experiencing improvement in depressive manifestations and be ready to interact in a group
setting.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter
stating that her mother has not been able to leave her home for weeks because she is afraid to
be outdoors alone. the nurse should anticipate planning care for managing which of the
following phobias?
, a. Xenophobia
b. Acrophobia
c. Mysophobia
d. Agoraphobia - -correct ans- -d. Agoraphobia
Agoraphobia is an irrational fear about being in places or circumstances where the client would
not have help in the event of panic or other forms of anxiety. Fear of being alone outdoor is a
common example.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions
and must take the medications at specific intervals when at home. Which of the following
instructions should the nurse include in the teaching?
a. "You really shouldn't change the schedule we established here in the facility."
b. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
c. "We'll have to talk to your provider about switching to an alternative schedule."
d. "It doesn't really matter what time you take your medications as long as you don't skip any
doses." - -correct ans- -b. "Let's work together to devise a time schedule that is convenient
for you on a daily basis."
This response illustrates the therapeutic communication technique of formulating a plan of
action. It demonstrates the nurse's willingness to work with the client to modify the schedule so
that it meets the client's needs at this time.
A nurse is providing discharge teaching to. client who has bipolar disorder and will be
discharged with a prescription for lithium. The nurse should teach the client that which of the
following factors puts her at risk for lithium toxicity? a. The client runs 4 miles outdoors every
afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 grams of sodium-containing foods daily.