1.A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse...

Question Answered step-by-step 1.A nurse is caring for a client who reports that he is angry withhis partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? a. Rationalization b. Denial c. Compensation d. Displacement 2. A nurse is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate? a. Please don’t take what the client said seriously when she is depressed b. It’s important that the client feel safe verbalizing how she is feeling c. Everybody feels that way about this client so don’t worry about it d. I’ll change your assignment to someone who doesn’t have depressive disorder 3. A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse? a. The child is 10 years old b. The child is homeschooled c. The child has no siblings d. The child has cystic fibrosis4. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam? a. Bradycardia b. Stupor c. Afebrile d. Hypertension 5.A nurse is assessing a client who is experiencing acute alcohol withdrawal. The nurse should anticipate that the provider will prescribe which of the following medications for the client? a. vareniclineb. clonidinec. diazepamd. buprenorphine 6. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Weigh the client twice a day b. Prepare the client for electroconvulsive therapy c. Set a weight gain goal of 2.2 g (5 lb.) per week d. Encourage the client to participate in family therapy 7. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect? a. Readily initiates conversation b. Enjoys imaginative play c. A strong relationship with siblings and peers d. Attachment to objects that spin 8. A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following is the priority intervention? a. Secure the client’s valuable possessions b. Limit loud noises in the client’s environment c. Encourage the client to participate in structured solitary activities. d. Provide high-calorie snacks to the client. 9. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication? a. Blocks aldehyde dehydrogenase b. Prevents the anxiety of abstinence c. Reduces substance craving d. Decreases the likelihood of seizures 10. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms? a. Repression b. Rationalization c. Introjection d. Intellectualization 11. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time? a. Contact the adolescent’s parents b. Suggest the adolescent join a support group c. Ask the adolescent if he is considering hurting himself d. Determine when the adolescent’s change in behavior began 12. nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Slurred speech b. Hypotension c. Bradycardia d. Hyperthermia 13. A nurse is assessing a client who has a histrionic personality disorder. Which of the following findings should the nurse expect? a. Lack of remorse b. Attention-seeking c. Splitting of staff d. Identity disturbance 14. A nurse is providing teaching to the daughter of an older adult client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching? a. “I will limit my mother’s clothing choices when she is getting dressed.” b. “I will provide my mother with detailed instructions about how to perform self-care.” c. “I will wake my mother up a couple of times in the night to check on her.” d. “I will discourage my mother from talking about her physical complaints.” 15. A nurse is providing teaching for a school-age child and his parent regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching? a. “I will provide a low-sodium diet for my son.” b. “I will make sure my son takes the last dose of the day by 4 p.m.” c. “I should expect my son to develop hand tremors.” d. “I should contact my doctor if my son urinates excessively.”16. A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take? a. Withhold the next dose of lithium. b. Repeat the lithium level test. c. Administer the next dose of lithium. d. Recommend a low-sodium diet 17. A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive-behavioral family therapy in response to which of the following client statements? a. “I want to learn how to change the way I react to problems with my family.” b. “I want to understand why my past experiences are affecting my family relationships.” c. “I want to improve my family’s understanding of each other’s boundaries.” d. “I want each of my family members to be more aware of each other’s feelings.” 18. A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client? a. Outside doors have locks b. The bed is in the low position c. Hallways are long distances d. The room has an area rug 19. A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching? a. “If I cut myself, I can clean the wound with isopropyl alcohol” b. “I can wear my cologne on special occasions” c. “When I bake my favorite cookies, I can use pure vanilla extract for flavoring” d. “I can continue to eat aged cheese and chocolate” 20. A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching? a. “I should avoid being around others if I think I’m having a relapse” b. “I should let my counselor know if I am having trouble sleeping” c. “I shouldn’t worry about the voices because they are a part of my illness” d. “I should increase my carbohydrate intake to maintain my energy level” 21. A nurse is assessing a client for negative manifestations of schizophrenia. Which of the following findings should the nurse expect? a. Echopraxia b. Delusions c. Anergia d. Tangentiality 22. A nurse is caring for a school-age child who has a fractured arm. The child has other injuries that cause the nurse to suspect abuse. Which of the following actions is appropriate for the nurse to take when assessing the child’s situation? a. Ask the parents directly if the child’s fracture is due to physical abuse b. Direct the parents to the waiting room before interviewing the child c. Interview the child with the provider and social worker present d. Ask clarifying questions as the child explains how the injuries occurred 23. A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse? a. Rapid mood swings b. Command hallucinations c. Impaired memory d. Inappropriate speech patterns Health Science Science Nursing NURS 2488 Share QuestionEmailCopy link Comments (0)