The nurse observes the clients violent
Week 3 Prep-U: Cognition and Interpersonal Relationships
1. A nurse tells a client, "I'll come back in 10 minutes to reassess your pain." When the nurse returns in 10 minutes, which aspect of
o Trust
2. A client with Alzheimer's disease tells the nurse, "I'm so afraid. Where am I? Where is my family?" What is the best response by
o "You're in the hospital, and you're safe here. Your family will return at 10 o'clock, which is one hour from now."
3. A nurse on a rehabilitation unit is caring for a client with a head injury resulting from a motor vehicle collision. The nurse notes
o Encourage the client to participate cooperatively during therapy.
o Notify the client’s family and ask them to sit with the client during therapy.
o “I think you forgot that I’m Rachel, Mrs. Jones.”
o “Mrs. Jones, I told you already, I’m Rachel, and I don’t live down the street.”
o delirium
o cerebral abscess
o explain one's psychiatric diagnosis.
7. Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The
o "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood."
8. The nurse is administering medications to a client with advanced Alzheimer’s dementia who is confused to person, place, and
o Compare the name and ID number on the client’s wristband to the medication administration record.
9. A nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his
o risk for loneliness
o unilateral neglect
o "I want you to understand your dad's level of anxiety."
o "Reminding your dad that you have heard that story will help him stop."
o concreteness
o flight of ideas
o "Do you remember who I am or what day it is today?"
o “ There will be pancakes for breakfast this morning. After breakfast your partner will come for a visit”
o listening to music with headphones
o interacting with two other clients
o Loneliness—ask client to state who she believes to be her friends.
o Sadness—ask client to reveal how long she has felt this way.
o inability to state the home address
o memories regarding a vacation 5 years ago
o “It’s normal for people your age to forget things such as names.”
o “Tell me more about your forgetfulness. It’s not unusual for forgetfulness to occur.”
o “You’re in the hospital because of a drug problem; I’m one of the nurses who will help you.”
o “I’m here to help you beat your drug habit. But it’s you who will need to work hard.”
o blackout
o Hangover
o “There’s a broad spectrum of mental capabilities and physical characteristics of children with Down syndrome.”
o "Children with Down syndrome are often fearful of strangers and have difficulty making friends."
o “What supports are available for the long term?”
o “Does another hospital have a better treatment?”
o is motivated to enter an alcohol rehabilitation program.
o breaks down and cries.
o reaction formation
o denial
o Lie flat on the floor and extend the legs straight from the trunk.
o Bend forward at the waist with arms hanging freely.
o “New medications will make this disease manageable for you.”
o “This sounds distressing for you. What questions do you have?”
o elevated C-reactive protein levels
o hematuria
o decreased secretions and saliva
o ptosis
27. A nurse is caring or a client who has experienced frontal lobe damage in a car accident. Which psychosocial behaviors are
indications of this damage? Select all that apply.
o overt sexual behavior
o difficulty controlling temper
o Kindly, but firmly, state that aliens are in movies.
o Redirect the client with structured activities.
appropriate at this time? Select all that apply.
o State, “Do you understand the side effects of your medication?”
o Ask the client if they have recently taken any drugs or alcohol.
30. A client in an extremely agitated state is admitted to the psychiatric unit for an opioid overdose. What are important nursing
o Identify friends who may have additional details about this overdose.
o Identify the legal next of kin and acknowledge immediate family members.
o sore throat
o polyuria
this client likely to experience? Select all that apply.
o Actual loss
o Anticipatory loss
33. The nurse is planning care for a client admitted for vascular dementia. Which action is most appropriate in assisting the client
o Encourage client to complete as many activities as possible and provide ample time to complete them.
34. The nurse evaluates the client’s ability to instill eyedrops correctly. The client correctly demonstrates the procedure when the
o wipes the tip of the eyedrop applicator with a disposable tissue.
35. An older adult client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells,
o “Please come away from the door. I’ll show you your room.”
o "The door is locked to keep you from getting lost."
o putting the client's favorite belongings in a safe place so that he will not lose them
o giving the client his medications in liquid form to make certain that he swallows them
o It's characterized by an acute onset and lasts hours to a number of days.
38. The nurses assesses a client for physiologic responses to stress. Which finding would suggest to the nurse that the client is not
o increased respiratory rate
39. The client with bipolar disorder, manic phase, appears at the nurse's station wearing a transparent shirt, miniskirt, high heels, 10
o Ask the client to put on hospital pajamas until she can dress appropriately.
40. A new father indicates he feels left out of the new family relationship since he is not able to bond the same way as the
o “Bonding occurs later in the first year of life, and Dad can become involved when the infant is better able to recognize him.”
41. The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in
o Assign tasks in simple steps.
o Make frequent changes in the client's routine.
o Communicate openly and offer support.
o Relieve the client of all responsibilities.
o tying the child down
o bribery with money
o impaired social interaction related to boyfriend's expectations
o fear related to boyfriend's expectations
o arranging for tutoring in school work
o encouraging peer visitation.
o Use posters and in-service sessions on the unit to help educate the first nurse on racial diversity.
o Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated.
o Rationalization
o Compensation
o spouse
o minister
o "I guess Jan needs a dog as much as I do."
o "Jan's stuffed dog looks somewhat like my dog."
examination should the nurse document this information?
o insight
recognizes this as what defense mechanism?
o rationalization
client is improving?
o “I don’t think about killing myself as much as I used to.”
husband’s behavior may confirm her fears?
o disturbance in his sleep patterns
neonate. Which action would be most important for the nurse to do?
o Continue to provide praise and support to the client.
personnel (UAP) are discussing the client’s needs. The UAP says, “She is just showing off to try and get our sympathy. There is no
need for her to cut herself. Why would adolescents want to do such a thing to themselves?” What response by the charge nurse
o “It’s hard to see a young person harm herself as she does, but she has serious family issues and doesn’t know better
ways to handle them, so we have to help her with that.”
o Gather pertinent information and enter the room, asking the client and her family how the staff can be most helpful.
o Stay out of the client’s room to provide her and her family privacy.
o "Give your spouse time to get over it."
o "Let me speak with your spouse. Your spouse might be okay with it."
o State other voices are not heard, but do not argue.
o Encourage the ventilation of anger and frustration.
when they visit. What will be the nurse's initial action?
o Ask the client to describe how the family has been mean and assess for injuries.
care? Select all that apply.
o Assess the client’s nutritional status.
61. A client with bipolar disorder states, "There is nothing for me to contribute to the art therapy group." The client has a history of
nonparticipation in situations requiring communication with others. What is the nurse's best response?
62. In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to
you! Here is the world's smallest violin playing for you." Which role is the client playing?
63. A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does
not experience further confusion. Which measure if suggested by the family would the nurse discourage?
64. Which characteristic would make the nurse suspect that a client with changes in cognition has delirium?
o significant impairment in social or occupational functioning over time
conversation. How should the nurse respond?
o "I promise I won't tell anyone about the information you share with me today unless you give me permission to do so."
(46.7 kg), and talks incessantly about how fat the client is. Which measure should the nurse take first when caring for this client?
o Teach the client about nutrition, calories, and a balanced diet.
multiple, self-inflicted, superficial lacerations of the forearms. What is the nurse's best response?
o "I'm going to tell your physician. Do you want to tell me why you did that?"
68. Which client statement indicates an understanding of the risk of alcohol relapse?
o “I’ll have my support group sponsor keep the list of symptoms for me.”
o "It's a lot harder to deal with my pain than it would be to face my death."
o "It helps me feel better to talk about possible ways to commit suicide."
o pulling at clothes
o yelling at others
o Tell the UAP to take care of the linen bags himself.
o Advise the UAP to be more tolerant of his coworker.
that the client most likely has which problem?
o the onset of Alzheimer’s disease
to control use. Which coping mechanism is the client using?
o repression
victim is sitting away from the others and crying. Which action by the nurse would be best?
o Leave the wife alone to cry.
judicial mandate. Which statement is most suggestive of alcohol dependence?
o "I drink just a little on rare social occasions."
and stealing. Which trait is the nurse likely to uncover during assessment?
o history of gainful employment
people who were once familiar and is unable to identify common objects. What is the priority nursing diagnosis?
o Impaired communication skills
When working with this client, the nurse should use which approach?
o humor
developmental task of the young adult (ages 18 to 25) is:
o intimacy versus isolation.
The nurse interprets this statement as important to document as which area of the mental status examination?
o psychomotor behavior
Which response would the nurse find inconsistent with the profile of a battered partner?
o "The abuse adds spice to our relationship."
o Explain the experience of having delirium.
o Regain orientation to time and place.
o “I turn off the radio when we’re in another room.”
o “I tell her she’s wrong, and then I tell her what’s right.”
o sudden behavioral changes and anorexia.
o memory loss of a traumatic event and somatic distress.
o play cards with another client.
o participate in a game of charades.
nurse is most therapeutic?
o "Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary."
The first spouse reports a childhood marred by an abusive relationship with a parent. To assess for the likelihood of further
violence and abuse, the nurse should determine that the first spouse:
88. A home health nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse
is too exhausted to continue providing care alone. The adult children live too far away to provide relief on a weekly basis. Which
o recommending community resources for adult day care and respite care for the client
o asking whether friends or church members can help with errands or provide short periods of relief
o “Let’s talk about what brought you into treatment and why you now want to stop taking medication.”
o "You and your family came to the clinic for treatment, so you can terminate it whenever you wish."
o toothpaste
o antiseptic mouthwash
o “I’m a nurse in the program. The staff and I will help you through the program.”
o "I know someone who was successful after the fifth program."
o “Your parents told the health care provider that you do have a problem.”
o "Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body."
o 3
94. The nurse is teaching a client about alcoholism. Which statement indicates that the client understands the nurse’s teaching?
95. A client is admitted to an inpatient unit for treatment of recurrent anorexia nervosa. The client states that 1 month before
admission the spouse took the children, moved out of the family home, and filed for divorce. The nurse recognizes that the
o manipulate the spouse.
96. A client who is a victim of domestic violence is contemplating leaving the relationship. Which assessment should be a priority for
o reasons for remaining in the abusive relationship
97. In a toddler, which injury is most likely the result of child abuse?
98. The nurse is planning care for a client who has a history of making verbal threats and acting violently toward family members.
The client is currently displaying intense anger toward the staff. What nursing diagnosis is most appropriate?
99. For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which
nursing intervention is likely to be most effective?
100.Which measure should the nurse include in the plan of care for a client with alcohol withdrawal delirium?
o touching the client before saying anything
than usual. The spouse asks anxiously, “Do you think she will live?” Which response by the nurse is most appropriate?
o “This must be quite a shock. How long have you been married?”
indicates the need for additional teaching?
o "Alcohol dependency affects the entire family."
o Challenge the client's unrealistic statements.
o Seclude the client until the flashback ends.
o including the client in finding solutions to the problem
o encouraging the client to ventilate feelings
o Allow autonomy.
o Elicit feelings descriptions.
the client is available. After the nurse completes the initial assessment, what should the first priority be?
o instituting seizure precautions, obtaining vital signs frequently, and recording fluid intake and output
client asks the nurse how to become a member, the nurse should respond:
o "Your physician must refer you to this program."
intervention is the most important?
o Fill out the client's menu and make sure the client eats at least half of what is on the tray.
is appropriate for the nurse to make?
o "If you don't eat, it may be necessary to feed you by tube or I.V."
The client is disoriented and has a blood pressure of 189/75 mm Hg and a pulse of 96 bpm. The friend who is with the client
says, “My friend was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn’t have any.” What should
o Monitor vital signs every 15 minutes.
o Obtain a prescription to place the client in restraints, if needed.
that apply.
o “I hear your frustration about how your detoxification is going.”
o “I can ask your health care provider (HCP) if he thinks naltrexone might help you.”
112.A client is admitted to the emergency department having just used cocaine. The nurse should assess this client for which factors?
o mood swings
o feeling of euphoria
o The client pouts when they do not get their way.
o The client states that problems are not their fault.
o Administer PRN haloperidol as ordered.
o Encourage deep breathing.
115.While assessing a client diagnosed with impulse control disorder, the nurse observes the client’s violent, aggressive, and
assaultive behavior when having to wait for a lunch tray to be delivered from the dietary department. Which history and
o The client has no remorse about the inability to control behavior.
o The violent behavior is most often justified by a stressor.
o piloerection
o vomiting
o Place seizure pads on the bed.
o Monitor cardiac and respiratory status.
o After the client returns from home visits, ask the client if they have brought in any food, laxatives, or diuretics.
o Have highly structured mealtimes.
are appropriate for this client? Select all that apply.
o Weigh the client in same amount of clothing and facing away from scale at daily scheduled intervals.
o Have the client keep a self-monitoring journal as a coping strategy.
120.A client with severe osteoarthritis and decreased mobility is moved to an assisted living facility. The nurse notices that the client
o "How are you getting all this wine?"
o “I’m calling your health care provider (HCP) to have all of us to talk about better pain control without the wine.”
having anxiety, irritability, vomiting, diarrhea, and delirium, resulting in her inability to care for the baby. The husband says, “I
saw that my bottles of alprazolam and oxycodone were empty even though I have not been taking them.” What should the nurse
o Call the health care provider for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal.
122.A client known to have alcohol dependence is admitted to the emergency department with a temperature of 99° F (37.2° C), a
o Administer lorazepam 2 mg IM.
o Draw blood for a magnesium level.
o Take the client’s vital signs.
o Assess the client for other withdrawal symptoms.
mechanism?
o projection
her addiction, stating she was prescribed the alprazolam to control her “panic attacks.” Which procedures would be the most
important during the admission process? Select all that apply.
o Initiate withdrawal precautions.
