Answer Choices:
a. Report the laboratory results to the health care provider.
b. Give the next dose of the medication as prescribed.
c. Administer aspirin and force fluids.
d. Repeat the laboratory tests.
Answer:
a. Report the laboratory results to the health care provider.
Question: During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. How should the nurse respond? a. “You’ve turned the tables on me.” b. “Nurses direct the interviews with patients.” c. “Do not ask questions about my personal life.” d. “The time we spend together is to discuss your concerns.”
Answer Choices:
a. “You’ve turned the tables on me.”
b. “Nurses direct the interviews with patients.”
c. “Do not ask questions about my personal life.”
d. “The time we spend together is to discuss your concerns.”
Answer:
D
Question: A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies about giving advice? a. It is rarely helpful. b. It fosters independence. c. It lifts the burden of personal decision making. d. It helps the patient develop feelings of personal adequacy.
Answer Choices:
a. It is rarely helpful.
b. It fosters independence.
c. It lifts the burden of personal decision making.
d. It helps the patient develop feelings of personal adequacy.
Answer:
B
Question: For which patient behavior would limit setting be most essential?
Answer Choices:
a. Clings to the nurse and asks for advice about inconsequential matters.
b. Is flirtatious and provocative with staff members of the opposite sex.
c. Is hypervigilant and refuses to attend unit activities as prescribed.
d. Urges a suspicious patient to hit anyone who stares at them.
Answer:
d. Urges a suspicious patient to hit anyone who stares at them.
Question: A patient diagnosed with mental illness asks a psychiatric technician, “What’s the matter with me?” The technician replies, “Your wiring nuts need tightening.” The nurse who overheard the exchange should take action based on what principle?
Answer Choices:
a. Violation of the patient’s right to be treated with dignity and respect
Answer:
a. Violation of the patient’s right to be treated with dignity and respect
Question: The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care to be achieved within 3 days?
Answer Choices:
a. Patient describes feelings associated with loss and stress.
b. Patient meet own needs before considering the rights of others.
c. Patient will identify healthy coping behaviors in response to stressful events.
d. Patient will allow others to assume responsibility for major areas of own life.
Answer:
C. Patient will identify healthy coping behaviors in response to stressful events.
Question: A 40-year-old adult living with parents’ states, “I’m happy but I don’t socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them.” A nurse should identify interventions to improve which patient characteristic?
Answer Choices:
a. Self-concept
b. Overall happiness
c. Appraisal of reality
d. Control over behavior
Answer:
A. Self-concept
Question: A nurse physically assessing a patient diagnosed with somatic disorder should understand that which intervention is the priority?
Answer Choices:
a. Provide a thorough physical examination.
b. Avoid detailed discussion of the reported complaints.
c. Avoid suggesting the appropriateness of any medical testing.
d. Focus on both prescribed and OTC medications the client is taking.
Answer:
a. Provide a thorough physical examination.
Question: An individual experiencing sexual dysfunction blames it on their partner and suggests the person is both unattractive and unromantic. Which defense mechanism is evident?
Answer Choices:
a. Rationalization
b. Compensation
c. Introjection
d. Regression
Answer:
a. Rationalization
Question: Which client statement most supports a diagnosis of agoraphobia?
Answer Choices:
a. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
b. “I’m sure I’ll get over not wanting to leave home soon. It takes time.”
c. “When I have a good incentive to go out, I can do it.”
d. “My family says they like it now that I stay home.”
Answer:
a. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
Question: A patient prescribed lithium telephones the nurse at the clinic to say, “I’ve had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?” What instructions should the nurse provide?
Answer Choices:
a. “Restrict oral fluids for 24 hours and stay in bed.”
b. “Have someone bring you to the clinic immediately.”
c. “Drink a large glass of water with 1 teaspoon of salt added.”
d. “Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.”
Answer:
B
Question: A patient is taking lithium carbonate and the nurse obtains a blood level that indicates the medication level is 1 mEq/L. How will the nurse interpret this information about the medication level?
Answer Choices:
a. It requires no additional nursing intervention.
b. It is below recognized therapeutic serum limits.
c. It is above recognized therapeutic serum limits.
d. It indicates a need for immediate medical intervention.
Answer:
A
Question: A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment best supports this diagnosis?
Answer Choices:
a. “Since my father died, I’ve been short of breath and had sharp pains that go down my left arm, but I think it’s just indigestion.”
b. “I have daily problems with nausea, vomiting, and diarrhea. Medication is very hard and I think I’m getting secondary drenched.”
c. “Sexual intercourse is painful. I pretend as if I’m asleep so I can avoid it. I think it’s starting to cause problems with my marriage.”
d. “I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.”
Answer:
a. “Since my father died, I’ve been short of breath and had sharp pains that go down my left arm, but I think it’s just indigestion.”
Question: An adult diagnosed with conversion (functional neurological symptom) disorder says, “Our family has gotten along over the years by working together. My partner cooks and the children clean house.” Understanding of this disorder will provide what rationalization for this statement?
Answer Choices:
a. Patient is receiving secondary gains from the symptoms.
b. Patient has problems with sexual identity and satisfaction.
c. Patient will be resistant to developing a trusting relationship.
d. Patient will benefit from confrontation about physical complaints.
Answer:
a. Patient is receiving secondary gains from the symptoms.
Question: A therapist recently convicted of multiple counts of Medicare fraud says, “Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too.” These statements demonstrate which personal characteristic?
Answer Choices:
a. Shame
b. Anxiousness
c. Superficial remorse
d. Absence of guilt
Answer:
d. Absence of guilt
Question: A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” What nursing intervention is most helpful for assisting the student?
Answer Choices:
a. Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects
b. Advising the student to discuss this experience with a health care provider
c. Encouraging the student to begin antioxidant vitamin supplements
d. Listening without comment
Answer:
a. Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects
Question: A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, “I feel like a failure. This baby is the root of my problems.” What is the priority nursing diagnosis?
Answer Choices:
a. Insomnia
b. Ineffective coping
c. Situational low self-esteem
d. Risk for other-directed violence
Answer:
D
Question: A nurse surveys the medical records for violations of patients’ rights. Which finding signals a violation?
Answer Choices:
a. No treatment plan is present in record.
b. Patient belongings were searched at admission.
c. Physical restraints were used to prevent harm to self.
d. Patient is placed on one-to-one continuous observation.
Answer:
a. No treatment plan is present in record.
Question: A patient prescribed a muscarinic-receptor blocker, will require assess for what side effect?
Answer Choices:
a. Dry mouth
b. Gynecomastia
c. Pseudoparkinsonism
d. Orthostatic hypotension
Answer:
A. Dry mouth
Question: “My nurse: (Select all that apply.)”
Answer Choices:
a. “The nursing staff helps me keep track of my medications.”
b. “My nurse is willing to go to social activities with me.”
c. “The staff lets me do whatever I choose without interfering.”
d. “My nurses look at me as a whole person with different needs.”
Answer:
A, B, E