A client says to a nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic respon... se by the nurse is: 1) "Have you shared your feelings with your family?" 2) "I think we should talk more about your anger with your family." 3) "You're feeling angry that your family continues to hope for you to be cured." 4) "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia." (ANS- 3) "You're feeling angry that your family continues to hope for you to be cured." On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which client behavior: 1) Fearfulness regarding treatment measures 2) Anger and aggressiveness directed towards others 3) An understanding of the pathology and symptoms of the diagnosis. 4) A willingness to participate in the planning the care and treatment plan. (ANS- 4) A willingness to participate in the planning the care and treatment plan. A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? 1) Planning short-term goals 2) Making appropriate referrals 3) Developing realistic solutions 4) Identifying expected outcomes (ANS- 2) Making appropriate referrals The nurse calls security and has physical restrains applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1) Libel 2) Battery 3) Assault 4) Slander 5) False Imprisonment (ANS- 2) Battery 3) Assault 5) False Imprisonment A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? 1) Exploring the client's ability to function 2) Exploring the client's potential for self-harm 3) Inquiring about the client's perception of appraisal of the neighbor's death 4) Inquiring about and examine the client's feelings that may block adaptive coping (ANS- 4) Inquiring about and examine the client's feelings that may block adaptive coping A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? 1) Denial 2) Projection 3) Rationalization 4) Intellectualization (ANS- 1) Denial Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? 1) Working 2) Trusting 3) Orientation 4) Termination (ANS- 4) Termination Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1) "Autonomy is the fundamental right of each and every client." 2) "A client's rights are guaranteed by both state and federal laws." 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4) "Regardless of the client's condition, all nurses have the duty to respect client rights." (ANS- 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurses's role in the termination stage of group development is to: 1) Encourage problem solving 2) Encourage accomplishment of the group's work 3) Acknowledge the contributions of each group member 4) Encourage members to become acquainted with one another (ANS- 3) Acknowledge the contributions of each group member A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: 1) Move the client next to the nurse's station 2) Use an indirect light source and turn off the television 3) Keep the television and a soft light on during the night 4) Play soft music during the night, and maintain a well-lit room (ANS- 2) Use an indirect light source and turn off the television A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A nurse suspects that the client may be experiencing a: 1) Psychosis 2) Repression 3) Conversion Disorder 4) Dissociative Disorder (ANS- 3) Conversion Disorder A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly states that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: 1) Orient the client to time, person, and place 2) Tell the client that the behavior is inappropriate 3) Escort the manic client to her room, with assistance 4) Tell the client that smoking privileges are revoked for 24 hours (ANS- 3) Escort the manic client to her room, with assistance A nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1) Provide safety for the client and other clients on the unit 2) Provide the clients on the unit with a sense of comfort and safety 3) Assist the staff in caring for the client in a controlled environment 4) Offer the client a less stimulated area to calm down and gain control (ANS- 1) Provide safety for the client and other clients on the unit Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. 1) Communicate expected behaviors to the client 2) Ensure that the client knows that he or she is not in charge of the nursing unit 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior (ANS- 1) Communicate expected behaviors to the client 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 2) "My attendance at the meetings has helped me to see that I provoke my husbands violence." 3) "I enjoy attending the meetings because they get me out of the house and away from my husband." 4) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics." (ANS- 1) "I no longer feel that I deserve the meetings my husband inflicts on me." [Show More]
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