Which activity would the nurse encourage for

Which activity would the nurse encourage for a depressed client who has feelings of failure and a low self-esteem? 1 Joining other clients in playing a board game 2 Singing in a karaoke contest to be held at the end of the week 3 Assisting a staff member in working on the monthly bulletin board 4 Selecting the movie to be played during the evening recreation period 2. Which behavior would the nurse expect from a client with a borderline personality disorder? 1 Act out to intimidate others. 2 Cooperate with the staff to gain praise. 3 Divide the staff into opposing factions to gain self-esteem. 4 Remain removed from others to avoid interacting with them. 3. Which outcome would be the priority for a cachectic, dehydrated adolescent who has taken enemas and laxatives several times a week and has engaged in self-induced vomiting? 1 Identify personal strengths 2 Control impulsive behaviors 3 Correct electrolyte imbalances 4 Develop a contract for treatment goals 4. Which common feature of mental illness is reflected when a client with severe mental illness informs the nurse that her coworkers are the ones with the “real problems” and states that she’s always “just had a short fuse”? 1 Relapse 2 Anosognosia 3 Nonadherence 4 Residual symptoms 5. Which response would the nurse make to a depressed client who asks, “Do you think they’ll ever let me out of here”? 1 “We should ask your primary health care provider.” 2 “Everyone says you’re doing fine.” 3 “Do you think you’re ready to leave?” 4 “How do you feel about leaving here?” 6. A school-aged child is brought to the clinic by the parent, who states, “Something is wrong. My child never seems happy and refuses to play.” When assessing this child for depressed behavior, with which response would the nurse initially begin? 1 “Tell me about yourself.” 2 “Let’s talk about what you do after school.” 3 “Can you tell me what’s making you so unhappy?” 4 “Why does your mother think that you’re unhappy?” 7. Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? 1 Shut the client’s door during the night. 2 Apply a vest restraint when the client is in bed. 3 Leave a dim light on in the client’s room at night. 4 Administer the client’s prescribed as-needed sedative medication. 8. Which signs and symptoms would the nurse find in a client who is in the depressive phase of bipolar I disorder? Select all that apply. One, some, or all responses may be correct. 1 Apathy 2 Hyperactivity 3 Flight of ideas 4 Loss of appetite 5 Sleep disturbances 9. Which initial approach would the nurse use to establish a therapeutic one-on-one relationship with a guarded, suspicious client diagnosed with schizophrenia? 1 Casual and honest 2 Warm and friendly 3 Permissive and distant 4 Undemanding and watchful 10. Which response would the nurse make to a hospitalized older depressed client who tells the nurse that life is no longer worth living? 1 “Why do you want to die?” 2 “Are you having thoughts about suicide?” 3 “You must be very depressed to feel that way.” 4 “Let’s focus on something positive in your life.” 11. Which approach would the nursing staff take to fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity? 1 Accepting that the client will eat when hungry 2 Allowing the client to prepare meals to eat when desired 3 Frequently offering high-calorie snacks that the client can hold 4 Leaving food in the client’s room that can be eaten when desired 12. Which initial intervention would the nurse implement for a client with major depression who is admitted to the hospital? 1 Introducing the client to one other client 2 Requiring participation in therapy sessions 3 Encouraging interaction with others in small groups 4 Conveying an attitude of concern that is not intrusive 13. Which factor would be essential to consider when the nurse determines whether a unit’s environment is conducive to psychological safety for a confused client with dementia? 1 Unit rules are flexible. 2 There is enough staff to rotate caregivers. 3 Realistic limits and controls are set. 4 Choices for social activities are numerous. 14. In which type of room would the nurse tell the admissions clerk to place a client with bipolar I disorder, manic phase? 1 Private 2 Isolation 3 Semi-private 4 Negative-airflow 15. Which clinical manifestations would the nurse observe in an older client with major depressive disorder? Select all that apply. One, some, or all responses may be correct. 1 Loss of memory 2 Decreased appetite 3 Neglect of personal hygiene 4 “I don’t know” answers to questions 5 “I can’t remember” answers to questions 16. Which essential, initial interventions would be included in the plan of care for a client admitted to the psychiatric unit during the first episode of an acute psychotic disorder? 1 Assessing the symptoms and teaching the client about the disorder 2 Encouraging participation in cognitive enhancement and providing social skills enhancement 3 Maintaining a daily routine and instituting family and group therapies 4 Instituting psychopharmacological prescriptions and offering supportive communication 17. Which action would the nurse take when implementing a tertiary preventive program for cognitively challenged children? 1 Teach children how to feed themselves. 2 Encourage the use of birth control by women. 3 Refer children for evaluation if they fail to meet developmental milestones. 4 Use the Denver Developmental Screening Test to evaluate children attending well-child clinics. 18. Which therapeutic nursing intervention would redirect a hyperactive, manic client? 1 Suggesting that the client write a short story 2 Having the client initiate group social activities on the unit 3 Asking the client to guide other clients as they clean their rooms 4 Encouraging the client to tear pictures out of magazines for a scrapbook 19. A client with a diagnosis of obsessive-compulsive disorder is often late for appointments because it takes so much time each day to complete a ritualistic hand-washing routine. Which is the most therapeutic nursing intervention? 1 Accepting the client’s ritual in a matter-of-fact manner without criticism 2 Encouraging the client to speed up the ritual so appointments can be met on time 3 Discouraging the client from washing the hands so frequently to prevent skin breakdown 4 Letting the client know how angry others become when the hand washing holds up activities 20. Which suicide method would indicate a low threat of lethality? 1 Hanging 2 Ingesting pills 3 Jumping from a tall bridge 4 Poisoning with carbon monoxide 21. Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment? 1 Level of interest in unit activities 2 Orientation to time, place, and person 3 Ability to perform tasks without becoming frustrated 4 Cognitive impairment, which will increase until adjustment to the home is accomplished 22. The home health nurse assesses the client with acquired immunodeficiency syndrome (AIDS) for which signs of altered mental health function associated with AIDS? Select all that apply. One, some, or all responses may be correct. 1 Delusions 2 Memory loss 3 Hopelessness 4 Hyperactivity 5 Paranoid thinking 23. Which initial intervention would be implemented when a depressed client says, “I’m no good. I’m better off dead”? 1 Respond, “I’ll stay with you until you’re less depressed.” 2 Reply, “I think you’re good; you should think about living.” 3 Alert the staff to schedule a 24-hour observation of the client. 4 Unobtrusively remove those articles that may be used in a suicide attempt. 24. Which environment would be conducive to reducing emotional stress and providing psychological safety for a client with generalized anxiety disorder? 1 One where all needs are met 2 One in which realistic limits and controls are set 3 One in which the client’s requests are met promptly 4 One where the client’s environment is kept neat and orderly 25. Which assessment data would the nurse find in a client who was recently admitted with a diagnosis of bulimia nervosa? 1 Amenorrhea in postmenarchal female 2 Lack of control over binge-eating episodes 3 Body weight less than 85% of that expected 4 Inability to purge in public places after eating 26. Which statement from the client would alert the nurse the client is experiencing a hallucination? 1 “I am going to save the world because I am God.” 2 “My insides smell like they’re going to just rot away.” 3 “Unless I gamble at least once a week, I feel extremely anxious.” 4 “It’s crazy, but I keep thinking that something terrible will happen to my baby.” 27. Which information would the school nurse include in an educational program on attention-deficit/hyperactivity disorder (ADHD) to the staff of an elementary school? 1 It becomes evident after age 12 years. 2 Its major clinical manifestation is easy distractibility. 3 It occurs more often in lower socioeconomic groups. 4 It causes affected children to sleep more than unaffected children. 28. Which action would the school nurse take for a child who tells the nurse, “My father has been getting into bed with me at night and touching me”? 1 Ask the child to describe the touching. 2 Talk to the teacher about any inappropriate behavior. 3 Contact the father to come to the school immediately. 4 Report the child’s conversation to child protective services. 29. Which short-term client outcome would be priority for a client who has attempted suicide? 1 Strengthening coping skills 2 Establishing a no-suicide contract 3 Learning problem-solving techniques 4 Recognizing why suicide was attempted 30. Which intervention would the nurse implement for a client prescribed haloperidol for schizophrenia? Select all that apply. One, some, or all responses may be correct. 1 Using the gluteal site only 2 Administering the medication every 3 months 3 Shaking the medication vigorously before administering 4 Using the Z-track method for all irritation medications 5 When initiating, giving the first two injections using the deltoid site 6 Monitoring the client for excess sedation for 3 hours postinjection SCIENCE HEALTH SCIENCE NURSING NUR 3290

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