AND ANSWERS GRADED A+ 2025
A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as
indicating which defense mechanism?
A. Denial
B. Projection
C. Rationalization
D. Intellectualization
A. Denial
Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic
nurse-client relationship?
A. Working
B. Trusting
C. Orientation
D. Termination
D. Termination
Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each
client's rights are respected?
A. "Autonomy is the fundamental right of each and every client"
B. "A client's rights are guaranteed by both state and federal laws"
C. "Being respectful and concerned will ensure that I'm attentive to my client's rights"
D. "Regardless of the client's condition, all nurses have the duty to respect client rights"
C. "Being respectful and concerned will ensure that I'm attentive to my client's rights"
,An LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy
session. The nurse's role in the termination stage of group development is to:
A. Encourage problem solving
B. Encourage accomplishment of the group's work
C. Acknowledge the contributions of each group member
D. Encourage members to become acquainted with one another
C. Acknowledge the contributions of each group member
A male client with delirium becomes disoriented and confused in his room at night. The best initial
nursing intervention is to:
A. Move the client next to the nurse's station
B. Use an indirect light source and turn off the television
C. Keep the television and a soft light on during the night
D. Play soft music during the night and maintain a well-lit room
B. Use an indirect light source and turn off the television
A client is admitted to a medical nursing unit with a diagnosis of acute blindness, many tests are
performed, and there seems to be no organic reason why this client cannot see. The client became blind
after witnessing a hit-and-run car accident, when a family of three was killed. An LPN/LVN suspects that
the client may be experiencing:
A. Psychosis
B. Repression
C. Conversion Disorder
D. Dissociative Disorder
,C. Conversion Disorder
A manic client announces to everyone in the day room that a stripper is coming to perform this evening.
When a nurse firmly state that this is inappropriate and will not happen, the client becomes verbally
abusive and threatens physical violence to the nurse. Based on the analysis of the situation, the
LPN/LVN determines that the appropriate action would be to:
A. Orient the client to time, person, and place
B. Tell the client that behavior is inappropriate.
C. Escort the manic client to her room with assistance
D. Tell the client that smoking privileges are revoked for 24 hours
C. Escort the manic client to her room with assistance
An LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's
speech pattern is rapid and affect is belligerent. Based on these observations, the nurse's immediate
priority of care is to:
A. Provide safety for the client and other clients on the unit
B. Provide the clients on the unit with a sense of comfort and safety
C. Assist the staff in caring for the client in a controlled environment
D. Offer the client a less stimulated area to calm down and gain control
A. Provide safety for the client and other clients on the unit
A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should
have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates
therapeutic communication?
A. "You have everything to live for."
B. "Why do you see yourself as a failure?"
, C. "Feeling like this is all part of being depressed."
D. "You've been feeling like a failure for a while?"
D. "You've been feeling like a failure for a while?"
When the community health nurse visits a patient at home, the patient states, "I haven't slept the last
couple of nights." Which response by the nurse illustrates a therapeutic communication response to this
patient?
A. "I see."
B. "Really?"
C. "You're having difficulty sleeping?"
D. "Sometimes, I have trouble sleeping too."
C. "You're having difficulty sleeping?"
A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which
communication technique should the nurse use to encourage the patient to eat?
A. Using open-ended questions and silence
B. Sharing personal preference regarding food choices
C. Documenting reasons why the patient does not want to eat
D. Offering opinions about the necessity of adequate nutrition
A. Using open-ended questions and silence
A patient admitted to a mental health unit for treatment of psychotic behavior spends hours at the
locked exit door shouting. "Let me out. There's nothing wrong with me. I don't belong here." What
defense mechanism is the patient implementing?
A. Denial
B. Projection