N244 WEEK 4 EXAM QUESTIONS WITH
100% ACCURATE ANSWERS
Which data indicates to the nurse that a client may be experiencing ineffective coping?
Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In
response to a death, ineffective coping is manifested by an extreme behavior that in some
instances may be harmful to the individual, physically, psychologically, or both. Option 1 is
indicative of a behavior that identifies an ineffective coping behavior as part of the grieving
process.
Which client is most likely at risk to become a victim of elder abuse?
A 90-year-old woman with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes physical
and psychological abuse, the misuse of property, and the violation of rights. The typical abuse
victim is a woman of advanced age with few social contacts and at least one physical or mental
impairment that limits her ability to perform activities of daily living. In addition, the client
usually lives alone or with the abuser and depends on the abuser for care.
Which data collection finding would indicate the possibility of the sexual abuse of a child?
Swelling of the genitals
A nurse is assigned to care for a client who is experiencing disturbed thought processes.
The nurse is told that the client believes that the food is being poisoned. Which
communication technique does the nurse plan to use to encourage the client to eat?
Open-ended questions and silence
Open-ended questions and silence are strategies used to encourage clients to discuss their
problem. Should encourage the client to identify the reasons for the behavior.
,A nurse is assigned to care for a client admitted to the hospital after sustaining an injury
from a house fire. The client attempted to save a neighbor involved in the fire but, in spite
of the client's efforts, the neighbor died. Which action would the nurse take to enable the
client to work through the meaning of the crisis?
Inquiring about the client's feelings that may affect coping
The client must first deal with feelings and negative responses before the client is able to work
through the meaning of the crisis.
A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The
nurse reviews the data obtained and identifies which of the following as a priority concern?
The client's report of suicidal thoughts
The client's thoughts are extremely important when verbalized. Suicidal thoughts are the highest
priority.
Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client's blood, the
client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present
at the time should respond by stating which of the following?
"Are you fearful and think that others may want to hurt you?"
Option 3 is the only option that recognizes the client's need. This response helps the client focus
on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change
the client's mind, the delusion may, in fact, be even more strongly held
An intoxicated client is brought to the emergency department by local police. The client is
told that the health care provider (HCP) will be in to see the client in about 30 minutes. The
client becomes very loud and offensive and wants to be seen by the HCP immediately. The
nurse assisting to care for the client would plan for which appropriate nursing
intervention?
,Offer to take the client to an examination room until he or she can be treated.
Safety of the client, other clients, and staff is of prime concern. When dealing with an impaired
individual, trying to talk may be out of the question. Waiting to intervene could cause the client
to become even more agitated and a threat to others
A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is
at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I
don't belong here!" The nurse identifies this behavior as:
Denial
Denial is refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and attributes
them to other people, objects, or situations.
In regression, the client returns to an earlier, more comforting, although less mature way of
behaving.
Rationalization is justifying the unacceptable attributes about oneself.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a
'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." The
therapeutic response by the nurse is:
"You're feeling angry that your family continues to hope for you to be 'cured'?"
Reflection is the therapeutic communication technique that redirects the client's feelings back to
validate what the client is saying.
A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago.
On review of the client's record, the nurse notes that the admission was a voluntary
admission. Based on this type of admission, the nurse would expect which of the following?
, The client will participate in the treatment plan.
Generally, voluntary admission is sought by the client or client's guardian. If the client seeks
voluntary admission, the most likely expectation is that the client will participate in the treatment
program.
A licensed practical nurse (LPN) enters a client's room, and the client is demanding release
from the hospital. The LPN reviews the client's record and notes that the client was
admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a
voluntary admission. The LPN reports the findings to the registered nurse (RN) and
expects that the RN will take which of the following actions?
Contact the health care provider (HCP).
Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients
have the right to demand and obtain release. The best nursing action is to contact the HCP.
A client is admitted to the psychiatric nursing unit. When collecting data from the client,
the nurse notes that the client was admitted on an involuntary status. Based on this type of
admission, the nurse likely expects that the client:
Presents a harm to self
Involuntary admission is made without the client's consent. Involuntary admission is necessary
when a person is a danger to self or others or is in need of psychiatric treatment or physical care
Following a group therapy session, a client approaches the licensed practical nurse (LPN)
and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the
findings to the registered nurse (RN) and expects that the RN will take which of the
following actions?
Get a written prescription from the health care provider (HCP) and obtain an informed consent.
A client may request to be secluded or restrained. Federal laws require the consent of the client,
unless an emergency situation exists in which an immediate risk to the client or others can be
100% ACCURATE ANSWERS
Which data indicates to the nurse that a client may be experiencing ineffective coping?
Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In
response to a death, ineffective coping is manifested by an extreme behavior that in some
instances may be harmful to the individual, physically, psychologically, or both. Option 1 is
indicative of a behavior that identifies an ineffective coping behavior as part of the grieving
process.
Which client is most likely at risk to become a victim of elder abuse?
A 90-year-old woman with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes physical
and psychological abuse, the misuse of property, and the violation of rights. The typical abuse
victim is a woman of advanced age with few social contacts and at least one physical or mental
impairment that limits her ability to perform activities of daily living. In addition, the client
usually lives alone or with the abuser and depends on the abuser for care.
Which data collection finding would indicate the possibility of the sexual abuse of a child?
Swelling of the genitals
A nurse is assigned to care for a client who is experiencing disturbed thought processes.
The nurse is told that the client believes that the food is being poisoned. Which
communication technique does the nurse plan to use to encourage the client to eat?
Open-ended questions and silence
Open-ended questions and silence are strategies used to encourage clients to discuss their
problem. Should encourage the client to identify the reasons for the behavior.
,A nurse is assigned to care for a client admitted to the hospital after sustaining an injury
from a house fire. The client attempted to save a neighbor involved in the fire but, in spite
of the client's efforts, the neighbor died. Which action would the nurse take to enable the
client to work through the meaning of the crisis?
Inquiring about the client's feelings that may affect coping
The client must first deal with feelings and negative responses before the client is able to work
through the meaning of the crisis.
A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The
nurse reviews the data obtained and identifies which of the following as a priority concern?
The client's report of suicidal thoughts
The client's thoughts are extremely important when verbalized. Suicidal thoughts are the highest
priority.
Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client's blood, the
client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present
at the time should respond by stating which of the following?
"Are you fearful and think that others may want to hurt you?"
Option 3 is the only option that recognizes the client's need. This response helps the client focus
on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change
the client's mind, the delusion may, in fact, be even more strongly held
An intoxicated client is brought to the emergency department by local police. The client is
told that the health care provider (HCP) will be in to see the client in about 30 minutes. The
client becomes very loud and offensive and wants to be seen by the HCP immediately. The
nurse assisting to care for the client would plan for which appropriate nursing
intervention?
,Offer to take the client to an examination room until he or she can be treated.
Safety of the client, other clients, and staff is of prime concern. When dealing with an impaired
individual, trying to talk may be out of the question. Waiting to intervene could cause the client
to become even more agitated and a threat to others
A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is
at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I
don't belong here!" The nurse identifies this behavior as:
Denial
Denial is refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and attributes
them to other people, objects, or situations.
In regression, the client returns to an earlier, more comforting, although less mature way of
behaving.
Rationalization is justifying the unacceptable attributes about oneself.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a
'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." The
therapeutic response by the nurse is:
"You're feeling angry that your family continues to hope for you to be 'cured'?"
Reflection is the therapeutic communication technique that redirects the client's feelings back to
validate what the client is saying.
A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago.
On review of the client's record, the nurse notes that the admission was a voluntary
admission. Based on this type of admission, the nurse would expect which of the following?
, The client will participate in the treatment plan.
Generally, voluntary admission is sought by the client or client's guardian. If the client seeks
voluntary admission, the most likely expectation is that the client will participate in the treatment
program.
A licensed practical nurse (LPN) enters a client's room, and the client is demanding release
from the hospital. The LPN reviews the client's record and notes that the client was
admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a
voluntary admission. The LPN reports the findings to the registered nurse (RN) and
expects that the RN will take which of the following actions?
Contact the health care provider (HCP).
Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients
have the right to demand and obtain release. The best nursing action is to contact the HCP.
A client is admitted to the psychiatric nursing unit. When collecting data from the client,
the nurse notes that the client was admitted on an involuntary status. Based on this type of
admission, the nurse likely expects that the client:
Presents a harm to self
Involuntary admission is made without the client's consent. Involuntary admission is necessary
when a person is a danger to self or others or is in need of psychiatric treatment or physical care
Following a group therapy session, a client approaches the licensed practical nurse (LPN)
and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the
findings to the registered nurse (RN) and expects that the RN will take which of the
following actions?
Get a written prescription from the health care provider (HCP) and obtain an informed consent.
A client may request to be secluded or restrained. Federal laws require the consent of the client,
unless an emergency situation exists in which an immediate risk to the client or others can be
