answers verified to pass 2025
A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the
nurse if he can go for a walk on the grounds of the treatment center. When he
is told that his privileges do not include walking on the grounds, the client
becomes verbally abusive. Which approach should the nurse take?
Call a staff member to escort the client to his room.
Tell the client to talk to his healthcare provider about his privileges.
Remind the client of the unit rules.
Calmly address the client's inappropriate behavior. - correct answers D.
Calmly addressing inappropriate behavior minimizes escalation of the issue,
specifically that the behavior is unacceptable. The other approaches are not
indicated.
The nurse is planning the care for an adult client with acute depression. Which
intervention should the nurse implement to help the client deal with
depression?
Ensure that the client's day is filled with group activities.
Assist the client in exploring feelings of shame, anger, and guilt.
Allow the client to initiate and determine activities of daily living.
Encourage the client to explore the rationale for depression - correct answers
B.
,Depression is associated with feelings of shame, anger, and guilt. Exploring
such feelings with the client is an important nursing intervention for a client
who is acutely depressed. The other interventions are not indicated.
A client who is diagnosed with schizophrenia is admitted to the hospital. The
nurse assesses the client's mental status. Which assessment finding is
characteristic of a client with schizophrenia?
Mood swings.
Extreme sadness.
Manipulative behavior.
Flat affect. - correct answers D.
Disinterest, and diminished or lack of facial expression is characteristic of
schizophrenia and is referred to as a flat affect. The other findings are not
associated with schizophrenia.
An adult male client who was admitted to the mental health unit yesterday tells
the nurse that microchips were planted in his head for military surveillance of
his every move. Which response is best for the nurse to provide?
You are in the hospital, and I am the nurse caring for you.
It must be difficult for you to control your anxious feelings.
Go to occupational therapy and start a project.
You are not in a war area now; this is the United States. - correct answers C.
, Delusions, which are often well-fixed, often generate fear and isolation. The
nurse should help the client participate in activities that avoid focusing on the
false belief and encourage interaction with others. The other responses are
not indicated and do not distract the client or reassure that he is in a safe
place.
A nurse working in the emergency room of a children's hospital admits a child
whose injuries could have resulted from abuse. Which statement most
accurately describes the nurse's responsibility in cases of suspected child
abuse?
The nurse should obtain objective data such as x-rays before reporting
suspicions to the authorities.
The nurse should confirm any suspicions of child abuse with the healthcare
provider before reporting to the authorities.
The nurse should report any case of suspected child abuse to the nurse in
charge.
The nurse should note in the client's record any suspicions of child abuse so
that a history of such suspicions can be tracked.
Submit - correct answers C.
It is the nurse's legal responsibility to report all suspected cases of child
abuse. Notifying the charge nurse starts the legal reporting process.
An older female client with advanced dementia is admitted to the hospital with
a fractured hip. The client repeatedly tells the staff, "Take me home. I want my
Mommy." Which response is best for the nurse to provide?
Orient the client to the time, place, and person.
Tell the client that the nurse is there and will help her.