NUR 112 Practice Assessment Mental Health Proctored Exam

"Please explain what you mean by the word 'nervous'." - A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make? Cranberry juice - A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the lunch tray? A. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back) - A nurse is assessing a client at a follow-up clinic for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? a. The client faces the direction of movement when sliding an object across the floor b. When pushing an object the client moves his front foot backward c. When moving an object to one side, the client pushes his weight on his heels d. The client stands with his feet close together when lifting an object c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider) - 4. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should this nurse take? a. Contact the pharmacy and confirm that the dosage is safe to administer b. Ask another nurse to verify that the dosage is appropriate for the client c. Contact the provider to question the dosage d. Inform the charge nurse and administer the dose of the medication the provider prescribed a. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding) - 5. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? a. Occupational therapist b. Social worker c. Registered dietician d. Speech pathologist NUR 112 Practice Assessment Mental Health Proctored Exam c. Interpersonal (interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth) - 6. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand) - 7. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? a. Make sure a family member is present to interpret for the staff. b. Determine the client's level of fluency in his primary language c. Speak directly to the interpreter when teaching the client d. Encourage the client to nod to indicate understanding c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client) - 8. A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? a. Nurse b. Anesthesiologist c. Surgeon d. Surgical suite nurse a. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion) - 9. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). which of the following actions should the nurse perform? a. Complete a neurological check b. Administer the prescribed PRN antihypertensive medication c. Increase the fluid intake d. Hold the client's evening dose of digoxin a. Documentation is a communication tool for the interprofessional health care team - 10. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? a. Documentation is a communication tool for the interprofessional health care team b. Documentation provides information to the client about financial charges for care provided c. Documentation provides information for a client audit d. Documentation allows providers to monitor the nurse's activities c. Washes and rinses her hands for 10 seconds - 11. A nurse is orienting a new assistive personal (AP) to the unit. For which of the following actions should the nurse intervene? a. Wears a gown when entering the room of a client who requires contact precautions b. Dons gloves to empty a urinary drainage device c. Washes and rinses her hands for 10 seconds d. Wears a respirator mask when entering the room of a client who requires airborne precautions c. Industry vs inferiority (a school age child (6-12) is in this stage of development) - 12. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning? a. Autonomy vs shame and doubt b. Initiative vs guilt c. Industry vs inferiority d. Identity vs role confusion b. Assigning tasks to an AP (delegation is considered indirect care) - 13. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? a. Determining the client's length of stay b. Assigning tasks to an AP c. Providing anticipatory guidance to a client in crisis d. Establishing the client's secondary medical diagnoses b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request) - 14. A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? a. Remind the client that a signed informed consent form is a legally binding document b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure c. Inform the surgical team to cancel the client's surgery d. Proceed with the preparation of the patient's surgical procedure b. Asking for an explanation - 15. A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks why the client needs to know this. Which of the following nontherapeutic communication techniques is the nurse using? a. Changing the subject b. Asking for an explanation c. Behaving defensively d. Arguing a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation) - 16. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? a. I'll apply ankle to my ankle today and tomorrow b. I'll rewrap my ankle starting from the knee down c. I'll bear weight on my ankle for 10 minutes every hour d. I'll put a heating pad on my ankle at bedtime tonight d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions) - 17. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. I will keep spare crutch tips handy b. I will bear the weight of my body on my hands c. I will inspect my crutches everyday for signs of wear d. I have a set of my brothers' crutches in the basement I can also use a. This service began with the client's admission to the hospital - 18. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. The cleint's family asks the nurse for info about this type of care. Which of the following explanations should the nurse provide? a. This service began with the client's admission to the hospital b. This service focuses on teaching the primary caregiver to meet the client's needs c. The emphasis is on the client's complete recovery from the illness or injury d. Services are centered in long-term care facilities a. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. It also helps the client deal with issues that are important to him) - 19. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront the client. Which of the following approaches should the nurse use when using confrontation? a. Point out inconsistences in the client's behavior b. Change the subject when the client behaves defiantly c. Use an aggressive tone of voice d. Wait to discuss the behavior in the presence of others a. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do) - 20. A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? a. They are more direct when discussing issues b. They are likely to wait for others to initiate conversation c. They tend to use more verbal communication d. They disclose more personal information a. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow) - 21. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. To which of the following rooms should the nurse assign the client? a. 208 b. 212 c. 214 d. 216 a. Education c. Gender d. Perception - 22. A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply) a. Education b. Feedback c. Gender d. Perception e. Time c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent) - 23. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Which of the following info should the nurse include? a. The nurse caring for the client at the time of death requests organ donation b. Donation costs are the responsibility of the donor's family and estate c. The nurse may serve as a witness to informed consent for organ donation d. Clients are placed on artificial life support before organ and tissue donation can occur a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury) - 24. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? a. I'll sit with my knees lower than my hips b. I'll do exercises that strengthen my abdominal muscles c. I'll wear low heeled shoes from now on d. I'll carry heavy objects close to my body d. Places clean linen that touched the floor in the soiled linen bag - 25. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? a. Shakes the soiled linen to remove any toilet paper remnants b. Places the soiled linen in the floor before bagging it c. Holds the soiled linen against her body while carrying it to the linen bag d. Places clean linen that touched the floor in the soiled linen bag d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion) - 26. A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? a. Increased insulin production b. Decreased RBC production c. Decreased sodium excretion d. Decreased calcium excretion c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown) - 27. A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Reposition the client every 3 hr b. Massage any bony prominences to promote circulation c. Provide the client with a diet high in protein d. Apply cornstarch to keep the skin dry b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid) - 28. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Report the incident to the charge nurse b. Wash the area of the puncture thoroughly with soap and water c. Complete an incident report d. Go to employee health services b. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case) - 29. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? a. Discussing a client's surgical procedure with the nurse manager b. Reporting laboratory findings to a member of the client's family c. Notifying the provider of physical exam findings d. Identifying the client by name when making a referral for home health services b. Perform the Heimlich maneuver - 30. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take? a. Observe the client before taking further actions b. Perform the Heimlich maneuver c. Assist the client to the floor and begin mouth-to-mouth d. Slap the client on the back several times a. Bathe a client who had an amputation 2 days ago b. Assist a client to ambulate using a gait belt e. Feed a client who had a stroke 3 months ago - 31. A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to AP? Select all that apply. a. Bathe a client who had an amputation 2 days ago b. Assist a client to ambulate using a gait belt c. Review a low-sodium diet for the client who has hypertension d. Explain oral hygiene to a client receiving chemo e. Feed a client who had a stroke 3 months ago a. Broth b. Grape juice e. Lemon gelatin - 32. A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? Select all that apply. a. Broth b. Grape juice c. Nonfat milk d. Custard e. Lemon gelatin d. Use soap and water to wash the catheter after each use - 33. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Which of the following instructions should the nurse include? a. Perform catheterization when you recognize the urge to void b. Hold the penis at a 30 to 45 degree angle when inserting the catheter c. Inflate the balloon when the urine flow stops d. Use soap and water to wash the catheter after each use c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage) - 34. A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion? a. This stage involves constructive efforts on the part of the group members b. This stage is when testing occurs to identify boundaries of interpersonal behaviors c. Consensus evolves in this stage d. Resistance is evident as subgroups form in this stage c. Discard the tablet and obtain another dose of medication - 35. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? a. Use the tablet's packaging to pick it up from the counter b. Wash the tablet off with alcohol and place it in a clean medicine cup c. Discard the tablet and obtain another dose of medication d. Place the tablet directly into a medication cup d. Reflection - 36. A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" the nurse responds: "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques? a. Clarifying b. Focusing c. Paraphrasing d. Reflection c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation) - 37. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? a. Limit the client's fluid intake in the evening b. Obtain a bedside commode for the client's use c. Leave a nightlight on in the client's room d. Put the side rails up and tell the client to call the nurse before voiding d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device) - 38. A nurse is preparing to move a client who is only partially able to assist up in a bed. Which of the following methods should the nurse plan to use? a. One nurse lifting as the client pushes with his feet b. Two nurses lifting the client under the shoulders