N161 FINAL EXAM WITH FULL PACK SOLUTIONS
1.A hgeriatric hnurse his hteaching hthe hclient's hfamily habout hthe hpossible
hcause hof hdelirium. hWhich hstatement hby hthe hnurse his hmost haccurate?
1. "Taking hmultiple hmedications hmay hlead hto hadverse hinteractions hor
htoxicity."
2. "Age-related hcognitive hchanges hmay hlead hto halterations hin hmental
hstatus."
3. "Lack hof hrigorous hexercise hmay hlead hto hdecreased hcerebral hblood hflow.
4. "Decreased hsocial hinteraction hmay hlead hto hprofound hisolation hand
hpsy- hchosis.": hANS: h1
The hnurse hshould hidentify hthat htaking hmultiple hmedications hthat hmay
hlead hto hadverse hreactions hor htoxicity his ha hrisk hfactor hfor hthe
hdevelopment hof hdelirium hin holder hadults.
2.A hhighly hagitated hclient hpaces hthe hunit hand hstates, h"I hcould hbuy hand
hsell hthis hplace." hThe hclient's hmood hfluctuates hfrom hfits hof hlaughter hto
houtbursts hof hanger. hWhich his hthe hmost haccurate hdocumentation hof hthis
hclient's hbehavior?
1. "Rates hmood h8/10. hExhibiting hlooseness hof hassociation. hEuphoric."
2. "Mood heuthymic. hExhibiting hmagical hthinking. hRestless."
3. "Mood hlabile. hExhibiting hdelusions hof hreference. hHyperactive."
1 h/
h131
,4. "Agitated hand hpacing. hExhibiting hgrandiosity. hMood hlabile.": hANS: h4
The hnurse hshould hdocument hthat hthis hclient's hbehavior his h"Agitated
hand hpacing. hEx- hhibiting hgrandiosity. hMood hlabile." hThe hclient his
hexhibiting hmood hswings hfrom heuphoria hto hirritability. hGrandiosity
hrefers hto hthe hattitude hthat hone's habilities hare hbetter hthan heveryone
helse's.
3.During han hassessment hinterview, ha hclient hdiagnosed hwith hantisocial
hperson- hality hdisorder hspits, hcurses, hand hrefuses hto hanswer hquestions.
hWhich his hthe happropriate hnursing hresponse hto hthis hbehavior?
1. "You hare hvery hdisrespectful. hYou hneed hto hlearn hto hcontrol hyourself."
2. "I hunderstand hthat hyou hare hangry, hbut hthis hbehavior hwill hnot hbe
htolerated."
3. "What hbehaviors hcould hyou hmodify hto himprove hthis hsituation?"
4. "What hantipersonality hdisorder hmedications hhave hhelped hyou hin hthe
hpast?"-
: hANS: h2
The happropriate hnursing hresponse his hto hreflect hthe hclient's hfeeling
hwhile hsetting hfirm hlimits hon hbehavior. hClients hdiagnosed hwith
hantisocial hpersonality hdisorder hhave ha hlow htolerance hfor hfrustration,
hsee hthemselves has hvictims, hand huse hprojection has ha hprimary hego
hdefense hmechanism.
4.A hkindergarten hstudent his hfrequently hviolent htoward hother hchildren. hA
hschool hnurse hnotices hbruises hand hburns hon hthe hchild's hface hand harms.
hWhat hother hsymptom hshould hindicate hto hthe hnurse hthat hthe hchild hmay
hhave hbeen hphysically habused?
1. The hchild hshrinks hat hthe happroach hof hadults.
2. The hchild hbegs hor hsteals hfood hor hmoney.
3. The hchild his hfrequently habsent hfrom hschool.
2 h/
h131
, 4. The hchild his hdelayed hin hphysical hand hemotional hdevelopment.: hANS: h1
The hnurse hshould hdetermine hthat ha hchild hwho hshrinks hat hthe happroach
hof hadults hin haddition hto hhaving hbruises hand hburns hmay hbe ha hvictim
hof habuse. hMaltreatment his hconsidered, hwhether hor hnot hthe hadult
hintended hto hharm hthe hchild.
5.What hshould hbe hthe hpriority hnursing hdiagnosis hfor ha hclient
hexperiencing halcohol hwithdrawal?
1. Risk hfor hinjury hR/T hcentral hnervous hsystem hstimulation
2. Disturbed hthought hprocesses hR/T htactile hhallucinations
3. Ineffective hcoping hR/T hpowerlessness hover halcohol huse
4. Ineffective hdenial hR/T hcontinued halcohol huse hdespite hnegative
hconse- hquences: hANS: h1
The hpriority hnursing hdiagnosis hfor ha hclient hexperiencing halcohol
hwithdrawal hshould hbe hrisk hfor hinjury hR/T hcentral hnervous hsystem
hstimulation. hAlcohol hwithdrawal hmay hinclude hthe hfollowing hsymptoms:
hcourse htremors hof hhands, htongue, hor heyelids; hnausea hor hvomiting;
hmalaise hor hweakness; htachycardia; hsweating; helevated hblood
hpressure; hanxiety; hdepressed hmood; hhallucinations; hheadache; hand
hinsomnia.
6.A hclient his hdiagnosed hwith hterminal hcancer. hWhich hsituation
hrepresents hKübler-Ross's hgrief hstage hof h"anger"?
1. The hclient hregisters hfor han hIronman hmarathon hto hbe hheld hin h9 hmonths.
2. The hclient his ha hdevout hCatholic hbut hrefuses hto hattend hchurch hand
hstates hthat hhis hfaith hhas hfailed hhim.
3. The hclient hpromises hGod hto hgive hup hsmoking hif hallowed hto hlive hlong
henough hto hwitness ha hgrandchild's hbirth.
4. The hclient hgathers hfamily hin horder hto hplan ha hfuneral hand hmake hlast
hwishes hknown.: hANS: h2
The hnurse hshould hassess hthat hthe hclient his hin hthe h"anger" hstage hof
hgrieving hwhen hthe hclient hrefuses hto hattend hchurch hand hstates hthat
hhis hfaith hhas hfailed hhim. hAnger his hthe hsecond hstage hof hKübler-Ross's
hgrief hprocess, hin hwhich hthe hreality hof hthe hsituation his hrealized, hand
hthe hindividual hhas hfeelings hof hsadness, hguilt, hshame, hhelplessness,
hand hhopelessness.
7.The hnurse heducator his hlecturing ha hgroup hof hnursing hstudents hon
hdepression hin hadolescents. hWhich hstatement hindicates hthat hteaching hhas
hbeen heffective?
1. "Adolescents hare hnot hlikely hto hsuffer hfrom hdepression."
2. "Depressed hadolescents halways hseek himmediate htreatment."
3 h/
h131
, 3. "Many hsymptoms hare hattributed hto hnormal hadjustments hof hadolescents.
4. "Suicide his hnot hcommon hamong hdepressed hadolescents.": hANS: h3
Many hsymptoms hof hdepression hmay hattributed hto hnormal hadjustments hof
hadolescents.
8.An hAfrican hAmerican hyouth, hgrowing hup hin han himpoverished
hneighborhood, hseeks haffiliation hwith ha hblack hgang. hSoon hhe his hengaging
hin htheft hand hassault.
4 h/
h131
1.A hgeriatric hnurse his hteaching hthe hclient's hfamily habout hthe hpossible
hcause hof hdelirium. hWhich hstatement hby hthe hnurse his hmost haccurate?
1. "Taking hmultiple hmedications hmay hlead hto hadverse hinteractions hor
htoxicity."
2. "Age-related hcognitive hchanges hmay hlead hto halterations hin hmental
hstatus."
3. "Lack hof hrigorous hexercise hmay hlead hto hdecreased hcerebral hblood hflow.
4. "Decreased hsocial hinteraction hmay hlead hto hprofound hisolation hand
hpsy- hchosis.": hANS: h1
The hnurse hshould hidentify hthat htaking hmultiple hmedications hthat hmay
hlead hto hadverse hreactions hor htoxicity his ha hrisk hfactor hfor hthe
hdevelopment hof hdelirium hin holder hadults.
2.A hhighly hagitated hclient hpaces hthe hunit hand hstates, h"I hcould hbuy hand
hsell hthis hplace." hThe hclient's hmood hfluctuates hfrom hfits hof hlaughter hto
houtbursts hof hanger. hWhich his hthe hmost haccurate hdocumentation hof hthis
hclient's hbehavior?
1. "Rates hmood h8/10. hExhibiting hlooseness hof hassociation. hEuphoric."
2. "Mood heuthymic. hExhibiting hmagical hthinking. hRestless."
3. "Mood hlabile. hExhibiting hdelusions hof hreference. hHyperactive."
1 h/
h131
,4. "Agitated hand hpacing. hExhibiting hgrandiosity. hMood hlabile.": hANS: h4
The hnurse hshould hdocument hthat hthis hclient's hbehavior his h"Agitated
hand hpacing. hEx- hhibiting hgrandiosity. hMood hlabile." hThe hclient his
hexhibiting hmood hswings hfrom heuphoria hto hirritability. hGrandiosity
hrefers hto hthe hattitude hthat hone's habilities hare hbetter hthan heveryone
helse's.
3.During han hassessment hinterview, ha hclient hdiagnosed hwith hantisocial
hperson- hality hdisorder hspits, hcurses, hand hrefuses hto hanswer hquestions.
hWhich his hthe happropriate hnursing hresponse hto hthis hbehavior?
1. "You hare hvery hdisrespectful. hYou hneed hto hlearn hto hcontrol hyourself."
2. "I hunderstand hthat hyou hare hangry, hbut hthis hbehavior hwill hnot hbe
htolerated."
3. "What hbehaviors hcould hyou hmodify hto himprove hthis hsituation?"
4. "What hantipersonality hdisorder hmedications hhave hhelped hyou hin hthe
hpast?"-
: hANS: h2
The happropriate hnursing hresponse his hto hreflect hthe hclient's hfeeling
hwhile hsetting hfirm hlimits hon hbehavior. hClients hdiagnosed hwith
hantisocial hpersonality hdisorder hhave ha hlow htolerance hfor hfrustration,
hsee hthemselves has hvictims, hand huse hprojection has ha hprimary hego
hdefense hmechanism.
4.A hkindergarten hstudent his hfrequently hviolent htoward hother hchildren. hA
hschool hnurse hnotices hbruises hand hburns hon hthe hchild's hface hand harms.
hWhat hother hsymptom hshould hindicate hto hthe hnurse hthat hthe hchild hmay
hhave hbeen hphysically habused?
1. The hchild hshrinks hat hthe happroach hof hadults.
2. The hchild hbegs hor hsteals hfood hor hmoney.
3. The hchild his hfrequently habsent hfrom hschool.
2 h/
h131
, 4. The hchild his hdelayed hin hphysical hand hemotional hdevelopment.: hANS: h1
The hnurse hshould hdetermine hthat ha hchild hwho hshrinks hat hthe happroach
hof hadults hin haddition hto hhaving hbruises hand hburns hmay hbe ha hvictim
hof habuse. hMaltreatment his hconsidered, hwhether hor hnot hthe hadult
hintended hto hharm hthe hchild.
5.What hshould hbe hthe hpriority hnursing hdiagnosis hfor ha hclient
hexperiencing halcohol hwithdrawal?
1. Risk hfor hinjury hR/T hcentral hnervous hsystem hstimulation
2. Disturbed hthought hprocesses hR/T htactile hhallucinations
3. Ineffective hcoping hR/T hpowerlessness hover halcohol huse
4. Ineffective hdenial hR/T hcontinued halcohol huse hdespite hnegative
hconse- hquences: hANS: h1
The hpriority hnursing hdiagnosis hfor ha hclient hexperiencing halcohol
hwithdrawal hshould hbe hrisk hfor hinjury hR/T hcentral hnervous hsystem
hstimulation. hAlcohol hwithdrawal hmay hinclude hthe hfollowing hsymptoms:
hcourse htremors hof hhands, htongue, hor heyelids; hnausea hor hvomiting;
hmalaise hor hweakness; htachycardia; hsweating; helevated hblood
hpressure; hanxiety; hdepressed hmood; hhallucinations; hheadache; hand
hinsomnia.
6.A hclient his hdiagnosed hwith hterminal hcancer. hWhich hsituation
hrepresents hKübler-Ross's hgrief hstage hof h"anger"?
1. The hclient hregisters hfor han hIronman hmarathon hto hbe hheld hin h9 hmonths.
2. The hclient his ha hdevout hCatholic hbut hrefuses hto hattend hchurch hand
hstates hthat hhis hfaith hhas hfailed hhim.
3. The hclient hpromises hGod hto hgive hup hsmoking hif hallowed hto hlive hlong
henough hto hwitness ha hgrandchild's hbirth.
4. The hclient hgathers hfamily hin horder hto hplan ha hfuneral hand hmake hlast
hwishes hknown.: hANS: h2
The hnurse hshould hassess hthat hthe hclient his hin hthe h"anger" hstage hof
hgrieving hwhen hthe hclient hrefuses hto hattend hchurch hand hstates hthat
hhis hfaith hhas hfailed hhim. hAnger his hthe hsecond hstage hof hKübler-Ross's
hgrief hprocess, hin hwhich hthe hreality hof hthe hsituation his hrealized, hand
hthe hindividual hhas hfeelings hof hsadness, hguilt, hshame, hhelplessness,
hand hhopelessness.
7.The hnurse heducator his hlecturing ha hgroup hof hnursing hstudents hon
hdepression hin hadolescents. hWhich hstatement hindicates hthat hteaching hhas
hbeen heffective?
1. "Adolescents hare hnot hlikely hto hsuffer hfrom hdepression."
2. "Depressed hadolescents halways hseek himmediate htreatment."
3 h/
h131
, 3. "Many hsymptoms hare hattributed hto hnormal hadjustments hof hadolescents.
4. "Suicide his hnot hcommon hamong hdepressed hadolescents.": hANS: h3
Many hsymptoms hof hdepression hmay hattributed hto hnormal hadjustments hof
hadolescents.
8.An hAfrican hAmerican hyouth, hgrowing hup hin han himpoverished
hneighborhood, hseeks haffiliation hwith ha hblack hgang. hSoon hhe his hengaging
hin htheft hand hassault.
4 h/
h131
