N161 Final
1.A geriatric nurse is teaching the client's family about the possible cause
of delirium. Which statement by the nurse is most accurate?
1. "Taking multiple medications may lead to adverse interactions or toxicity."
2. "Age-related cognitive changes may lead to alterations in mental status."
3. "Lack of rigorous exercise may lead to decreased cerebral blood flow."
4. "Decreased social interaction may lead to profound isolation and
psy- chosis.": ANS: 1
The nurse should identify that taking multiple medications that may
lead to adverse reactions or toxicity is a risk factor for the development
of delirium in older adults.
2.A highly agitated client paces the unit and states, "I could buy and sell
this place." The client's mood fluctuates from fits of laughter to outbursts of
anger. Which is the most accurate documentation of this client's behavior?
1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric."
2. "Mood euthymic. Exhibiting magical thinking. Restless."
3. "Mood labile. Exhibiting delusions of reference. Hyperactive."
4. "Agitated and pacing. Exhibiting grandiosity. Mood labile.": ANS: 4
The nurse should document that this client's behavior is "Agitated and
pacing. Ex- hibiting grandiosity. Mood labile." The client is exhibiting
mood swings from euphoria to irritability. Grandiosity refers to the
attitude that one's abilities are better than everyone else's.
3.During an assessment interview, a client diagnosed with antisocial
person- ality disorder spits, curses, and refuses to answer questions. Which
is the appropriate nursing response to this behavior?
1. "You are very disrespectful. You need to learn to control yourself."
2. "I understand that you are angry, but this behavior will not be tolerated."
3. "What behaviors could you modify to improve this situation?"
4. "What antipersonality disorder medications have helped you in the past?"-
: ANS: 2
The appropriate nursing response is to reflect the client's feeling while
setting firm limits on behavior. Clients diagnosed with antisocial
personality disorder have a low tolerance for frustration, see themselves
as victims, and use projection as a primary ego defense mechanism.
4.A kindergarten student is frequently violent toward other children. A
school nurse notices bruises and burns on the child's face and arms. What
other symptom should indicate to the nurse that the child may have been
physically abused?
1. The child shrinks at the approach of adults.
2. The child begs or steals food or money.
1/
128
, N161 Final
3. The child is frequently absent from school.
2/
128
, N161 Final
4. The child is delayed in physical and emotional development.: ANS: 1
The nurse should determine that a child who shrinks at the approach of
adults in addition to having bruises and burns may be a victim of abuse.
Maltreatment is considered, whether or not the adult intended to harm
the child.
5.What should be the priority nursing diagnosis for a client
experiencing alcohol withdrawal?
1. Risk for injury R/T central nervous system stimulation
2. Disturbed thought processes R/T tactile hallucinations
3. Ineffective coping R/T powerlessness over alcohol use
4. Ineffective denial R/T continued alcohol use despite negative
conse- quences: ANS: 1
The priority nursing diagnosis for a client experiencing alcohol withdrawal
should be risk for injury R/T central nervous system stimulation. Alcohol
withdrawal may include the following symptoms: course tremors of
hands, tongue, or eyelids; nausea or vomiting; malaise or weakness;
tachycardia; sweating; elevated blood pressure; anxiety; depressed
mood; hallucinations; headache; and insomnia.
6.A client is diagnosed with terminal cancer. Which situation
represents Kübler-Ross's grief stage of "anger"?
1. The client registers for an Ironman marathon to be held in 9 months.
2. The client is a devout Catholic but refuses to attend church and states
that his faith has failed him.
3. The client promises God to give up smoking if allowed to live long
enough to witness a grandchild's birth.
4. The client gathers family in order to plan a funeral and make last
wishes known.: ANS: 2
The nurse should assess that the client is in the "anger" stage of grieving
when the client refuses to attend church and states that his faith has
failed him. Anger is the second stage of Kübler-Ross's grief process, in
which the reality of the situation is realized, and the individual has
feelings of sadness, guilt, shame, helplessness, and hopelessness.
7.The nurse educator is lecturing a group of nursing students on
depression in adolescents. Which statement indicates that teaching has
been effective?
1. "Adolescents are not likely to suffer from depression."
2. "Depressed adolescents always seek immediate treatment."
3. "Many symptoms are attributed to normal adjustments of adolescents."
4. "Suicide is not common among depressed adolescents.": ANS: 3
3/
128
, N161 Final
Many symptoms of depression may attributed to normal adjustments of
adolescents.
8.An African American youth, growing up in an impoverished
neighborhood, seeks affiliation with a black gang. Soon he is engaging in
theft and assault.
4/
128
1.A geriatric nurse is teaching the client's family about the possible cause
of delirium. Which statement by the nurse is most accurate?
1. "Taking multiple medications may lead to adverse interactions or toxicity."
2. "Age-related cognitive changes may lead to alterations in mental status."
3. "Lack of rigorous exercise may lead to decreased cerebral blood flow."
4. "Decreased social interaction may lead to profound isolation and
psy- chosis.": ANS: 1
The nurse should identify that taking multiple medications that may
lead to adverse reactions or toxicity is a risk factor for the development
of delirium in older adults.
2.A highly agitated client paces the unit and states, "I could buy and sell
this place." The client's mood fluctuates from fits of laughter to outbursts of
anger. Which is the most accurate documentation of this client's behavior?
1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric."
2. "Mood euthymic. Exhibiting magical thinking. Restless."
3. "Mood labile. Exhibiting delusions of reference. Hyperactive."
4. "Agitated and pacing. Exhibiting grandiosity. Mood labile.": ANS: 4
The nurse should document that this client's behavior is "Agitated and
pacing. Ex- hibiting grandiosity. Mood labile." The client is exhibiting
mood swings from euphoria to irritability. Grandiosity refers to the
attitude that one's abilities are better than everyone else's.
3.During an assessment interview, a client diagnosed with antisocial
person- ality disorder spits, curses, and refuses to answer questions. Which
is the appropriate nursing response to this behavior?
1. "You are very disrespectful. You need to learn to control yourself."
2. "I understand that you are angry, but this behavior will not be tolerated."
3. "What behaviors could you modify to improve this situation?"
4. "What antipersonality disorder medications have helped you in the past?"-
: ANS: 2
The appropriate nursing response is to reflect the client's feeling while
setting firm limits on behavior. Clients diagnosed with antisocial
personality disorder have a low tolerance for frustration, see themselves
as victims, and use projection as a primary ego defense mechanism.
4.A kindergarten student is frequently violent toward other children. A
school nurse notices bruises and burns on the child's face and arms. What
other symptom should indicate to the nurse that the child may have been
physically abused?
1. The child shrinks at the approach of adults.
2. The child begs or steals food or money.
1/
128
, N161 Final
3. The child is frequently absent from school.
2/
128
, N161 Final
4. The child is delayed in physical and emotional development.: ANS: 1
The nurse should determine that a child who shrinks at the approach of
adults in addition to having bruises and burns may be a victim of abuse.
Maltreatment is considered, whether or not the adult intended to harm
the child.
5.What should be the priority nursing diagnosis for a client
experiencing alcohol withdrawal?
1. Risk for injury R/T central nervous system stimulation
2. Disturbed thought processes R/T tactile hallucinations
3. Ineffective coping R/T powerlessness over alcohol use
4. Ineffective denial R/T continued alcohol use despite negative
conse- quences: ANS: 1
The priority nursing diagnosis for a client experiencing alcohol withdrawal
should be risk for injury R/T central nervous system stimulation. Alcohol
withdrawal may include the following symptoms: course tremors of
hands, tongue, or eyelids; nausea or vomiting; malaise or weakness;
tachycardia; sweating; elevated blood pressure; anxiety; depressed
mood; hallucinations; headache; and insomnia.
6.A client is diagnosed with terminal cancer. Which situation
represents Kübler-Ross's grief stage of "anger"?
1. The client registers for an Ironman marathon to be held in 9 months.
2. The client is a devout Catholic but refuses to attend church and states
that his faith has failed him.
3. The client promises God to give up smoking if allowed to live long
enough to witness a grandchild's birth.
4. The client gathers family in order to plan a funeral and make last
wishes known.: ANS: 2
The nurse should assess that the client is in the "anger" stage of grieving
when the client refuses to attend church and states that his faith has
failed him. Anger is the second stage of Kübler-Ross's grief process, in
which the reality of the situation is realized, and the individual has
feelings of sadness, guilt, shame, helplessness, and hopelessness.
7.The nurse educator is lecturing a group of nursing students on
depression in adolescents. Which statement indicates that teaching has
been effective?
1. "Adolescents are not likely to suffer from depression."
2. "Depressed adolescents always seek immediate treatment."
3. "Many symptoms are attributed to normal adjustments of adolescents."
4. "Suicide is not common among depressed adolescents.": ANS: 3
3/
128
, N161 Final
Many symptoms of depression may attributed to normal adjustments of
adolescents.
8.An African American youth, growing up in an impoverished
neighborhood, seeks affiliation with a black gang. Soon he is engaging in
theft and assault.
4/
128
