MH exam 4

49問 • 1年前

問題一覧

The nurse is providing support to the family of a recently deceased client. A family member states, "My father took me fishing all the time. He can't physically take me anymore, but he will be watching over me. I really miss him, "The nurse recognizes the family member is experiencing

Mourning

The nurse educator is providing an in-service to nursing staff on a unit that has recently experienced and increase in client deaths. The nurse educator knows that a priority recommendation for nurses who are struggling to cope with all the loss is

Creating sustainable practice of self-care and balance

The nurse is caring for a client whose spouse of 52 years suddenly died. Which of the following statements by the nurse is most therapeutic.

"Your loved one was very special and will not be replaceable"

The nurse is caring for a client who is dying and in severe pain. Which of the following interventions should the nurse consider as the priority?

Support the clients family in grieving.

The nurse is caring for a terminally ill client. Which of the following statements by the nurse best demonstrates the art of presence?

"Would you like to talk about what this experience is like for you?"

The home health nurse is caring for a client who is dying from acquired immune deficiency syndrome (AIDS). The client is incompetent and asks the nurse to help with assisted suicide. The nurse tell the client they will not assist with the request. Which of the following ethical liberties is the nurse demonstrating?

Nonmaleficence

A nurse is caring for a client in hospice who is in the dying process. The family wants to put in a feeding tube because the client is refusing to eat. Which of the following statements by the nurse is appropriate therapeutic communication?

"Its natural for clients to refuse food at this stage and can be difficult for family members"

The nurse is caring for a client who is dying. The client tells the nurse, " I have worked hard all my life and now this, its not fair!" The nurse recognizes the phase of Kubler-Ross the client is experiencing is

Anger

The nurse is caring for assigned clients who have various diseases and is preparing a referral to hospice. The nurse recognizes which of the following clients as meeting the admission criteria?

92-year-old who has acute pneumonia and late-stage Alzheimer's disease with no insurance.

The nurse is caring for a client who has a terminal diagnosis and asks the nurse if physician-assisted suicide is allowed in every state. Which of the following responses by the nurse is appropriate?

"No, physician-assisted suicide is determined by state legislature. Tell me more about what you are thinking."

The school nurse is providing an in-service for parents about warning signs of eating disorders in children. A parent asks," Are poor graders a common warning sign for anorexia in children?" The appropriate response by the school nurse is

"No, children who are at risk for anorexia are often strive for academic excellence."

The nurse is caring for a client who is being admitted with bulimia nervosa. Which of the following information from the chart below should the nurse report immediately to the PCP?

Potassium

The nurse is caring for a client who is experiencing alcohol withdrawal and prescribed naltrexone. Which of the following information should the nurse teach the client regarding this medication?

Clients should be opiate-free for 10 days before initiation

The nurse is preparing to admit a client from the emergency department (ED) to the mental health unit. The nurse reviews the information in the chart below and recognizes the may be an instance of

Withdrawal

The nurse is caring for a 17-year-old female client who is being discharged from inpatient care with a diagnosis of anorexia. The family askes the nurse what type of therapy will be recommended. The correct response by the nurse is

"A combination of group and individualized therapy is recommended.

The new nurse is precepting on the mental health unit and tells the nurse preceptor there is an error in a client's chart. The chart says history of anorexia, but the client's reason for admission is bulimia. "Which of the following responses should the nurse preceptor tell the new nurse?

"It is possible for a client to have a history of both."

The nurse is developing a resource document about eating disorders for new nurses on the unit. The nurse includes that anorexia commonly occurs in clients who also have

Anxiety disorders

The nurse is caring for a client who is diagnosed with bulimia and recently prescribed fluoxetine (SSIR). Which of the following information should the nurse teach the client about this medication?

It is administered at a higher dose for bulimia than for depression

The nurse is caring for a client who was recently admitted with binge-purge bulimia. Which of the following actions is a priority for the nurse the perform?

Complete the clients electrocardiogram (ECG)

A school nurse is teaching high school students about the dangers of inhalant abuse. Which of the following should the nurse include in the teaching?

Inhalant abuse may cause a coma to occur

The nurse is caring for a client who is being seen for a well check-up visit. The client tells the nurse they have remained sober for the last 12 months and attended support meetings routinely. The nurse recognized that the client is in which of the following stages of change?

Maintenance stage

The nurse educator is providing a community education session about primary prevention of abuse. Which actions from the box should the nurse manager include in the teaching?

1.Reduce stress 2. Increase coping skills 5. Reduce the influence of risk factors A. 1,2,5

The nurse is caring for a postsurgical client who has a history of heavy alcohol intake and just returned to the nursing unit. The nurse should immediately notify the primary health care provider (PHCP) if the client states

"I am feeling diaphoretic and short of breath."

The nurse preceptor is reviewing the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DMS-5) with a newly hired nurse. It requires follow-up by the nurse preceptor if the newly hired nurse identifies which of the following substances as a pshychoactive?

Beta-blockers

The nurse is caring for a client who is trying to stop smoking. The client tells the nurse they are very interested in hypnosis. Which of the following is the most appropriate response for the nurse to make?

"Hypnosis can be successful, is this something you would like to consider?

The nurse manager is teaching nursing staff about identifying opioid intoxication. Which symptoms from the box should be include in the teaching?

Hypotension Slurred speech Sedation

The nurse is preparing to discharge assigned clients who have completed the detoxification process for alcohol addiction and to make referrals to AA. Which of the following clients is appropriate for the referral?

The client who askes for help to refrain from alcohol

The nurse is teaching a client who is being discharged after several weeks of inpatient hospitalization to treat opioid use disorder. The nurse determines client teaching has been effective when the client states

"I have oral surgery next week and will tell the dentist to refrain from prescribing a narcotic to manage my pain."

The nurse has attended a staff development conference about family violence. Which of the following statements by the nurse demonstrates a correct understanding about family violence?

Family violence in the most common form is neglect.

The nurse is caring for a client who has apparent facial and body bruising. The nurse should first focus on which of the following to meet the clients needs?

Establishing trust and building rapport

The nurse is conducting an interview with a victim of spousal abuse in the ED. Which of the following is most appropriate by the nurse?

How do you and your partner resolve disagreements?

The new nurse assisted other staff members to physically hold down a combative client while a chemical restraint was administered. After obtaining the primary health care providers (PHCP) prescription, the nurse preceptor informs the new nurse that which of the following should be preformed next?

Assess the client and document this information

The nurse is admitting a client for anger and aggressive behaviors. The nurse undertstands that aggressive behavior increases the client's risk factor for

Myocardial infarction (MI)

The nurse is examining a client who is believed to have been abused, and the spouse is in the room. The nurse knows that which of the following information is correct regarding people who are abusive?

They often suffer from ineffective coping skills

The nurse is discharging a client who was a victim of domestic abuse for several years. The client asks the nurse about group therapy. The appropriate response by the nurse is

Group therapy can be effective, lets find some options for you so you can start right away

The nurse is admitting an elderly client to the unit for a fractured hip. The nurse notices the client has a minor burn on the back and the client states that it is from a heating pad left on the area for too long. Which of the following interventions should the nurse preform?

Ask the client if someone close to them caused the injury

The nurse working in the ED enters a room to help with a rape kit assessment. The client asks the nurse, "what are you going to do?" The appropriate explanation by the nurse is

A detailed physical exam including a genital exam, and we will communicate everything we are going to do step by step

The nurse is caring for a client who is yelling, pacing, and has clenched fists. Some of the other clients appear afraid. Which of the following is an appropriate intervention by the nurse?

Remove the other clients from the area

The nurse manager working in the ED is assisting with evidence collection for a sexual assault victim. After consent is signed the nurse begins to collect evidence. The client states, "I don't want any photographs taken." Which of the following should the nurse preform next?

Refrain from taking photographs per the client's request

The nurse is providing care to multiple clients on a mental health unit. The nurse is aware of which of the following scenarios is associated with the greatest risk for violence directed at others?

The client who has bipolar disorder in the manic phase and is swinging a fork in the air

The nurse is teaching a group of parents about child abuse. The nurse included characteristics of abusive perpetrators in the presentation. Which of the following characteristics should the nurse include in the presentation?

Family authoritarianism

The nurse is assisting a client who has experienced intimate partner abuse to develop a safety plan, including a list of items to take if the client leaves the abusing partner. Which of the following items identified by the client requires follow-up teaching?

Personal hygiene items

The nurse educator is preparing and in-service for nurses working on the mental health unit about client aggressive behavior. The nurse educator knows an important factor for delivering quality care to clients with a history of aggressive behavior is the

Nurses self awareness

The nursing student asks the clinical instructor the explain the concept of the hospice team. The instructor advises the nursing student

Hospice teams are multidisciplinary and help to care for a dying client and their family

The nurse is listening to a client caregiver who is tired and irritable. Which of the following nursing interventions is the priority>

Secure additional resources for the clients evening and night care

The nurse preceptor is educating a group of new nurses about assessing the effectiveness of treatment for victims of sexual assault. The nurse preceptor advises that when victims report sleeping well with few episodes of nightmares, the victims are

Ready for group therapy instead of individualized therapy

The nurse manager is providing an in-service to nursing staff regarding palliative care for clients who have dementia. It demonstrates effective teaching if a staff member states

We should try to anticipate the clients needs to keep them calm

The nurse is caring for a client who is experiencing complicated grief. Which of the following interventions should the nurse perform to assist the client to resolve their grief?

Help the client talk about the good and bad aspects of the deceased

The nurse preceptor is observing a newly hired nurse providing care for a client in hospice who is experiencing severe pain. It requires immediate intervention if the preceptor observes the newly hired nurse

Expressing concern about giving the client more pain medication

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