NUR 213 - Exam 3|100% Complete With A+ Graded Answers
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Course
NUR 180
Institution
NUR 180
NUR 213 - Exam 3|100% Complete With A+ Graded Answers
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the ...
NUR 213 - Exam 3|100% Complete With A+
Graded Answers
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting
that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret
this behavior as a cue to modify the treatment plan?
1.
Suggesting a reduction of medication
2.
Allowing increased "in-room" activities
3.
Increasing the level of suicide precautions
4.
Allowing the client off-unit privileges as needed
3
(pt who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a
dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision
to harm himself or herself. Suicide precautions are necessary to keep the client safe)
The emergency department nurse is caring for an adult client who is a victim of family violence. Which
priority instruction should be included in the discharge instructions?
1.
Information regarding shelters
2.
Instructions regarding calling the police
3.
Instructions regarding self-defense classes
4.
Explaining the importance of leaving the violent situation
1
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels
"as though the rape just happened yesterday," even though it has been a few months since the
incident. Which is the most appropriate nursing response?
1.
"You need to try to be realistic. The rape did not just occur."
2.
"It will take some time to get over these feelings about your rape."
3.
"Tell me more about the incident that causes you to feel like the rape just occurred."
,4.
"What do you think that you can do to alleviate some of your fears about being raped again?"
3
(trash response irl though)
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can
best ensure client safety by which action?
1.
Requesting that a peer remain with the client at all times
2.
Removing the client's clothing and placing the client in a hospital gown
3.
Assigning to the client a staff member who will remain with the client at all times
4.
Admitting the client to a seclusion room where all potentially dangerous articles are removed
3
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may
be suicidal?
1.
The adolescent gives away a DVD and a cherished autographed picture of a performer.
2.
The adolescent runs out of the therapy group, swearing at the group leader, and to her room.
3.
The adolescent becomes angry while speaking on the telephone and slams down the receiver.
4.
The adolescent gets angry with her roommate when the roommate borrows the client's clothes
without asking.
1
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me."
Which is the nurse's best response?
1.
"Have you talked to your family about this?"
2.
"Everyone feels this way when they are depressed."
3.
"You will feel better once your medication begins to work."
4.
"You sound very upset. Are you thinking of hurting yourself?"
4
, A client is admitted with a recent history of severe anxiety following a home invasion and robbery.
During the initial assessment interview, which statement by the client should indicate to the nurse the
possible diagnosis of posttraumatic stress disorder? Select all that apply.
1.
"I'm afraid of spiders."
2.
"I keep reliving the robbery."
3.
"I see his face everywhere I go."
4.
"I don't want anything to eat now."
5.
"I might have died over a few dollars in my pocket."
6.
"I have to wash my hands over and over again many times."
235
(Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of
the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress
disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have
to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease
anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is
vague and could relate to numerous conditions)
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which
client symptoms require the nurse's immediate action?
1.
Incessant talking and sexual innuendoes
2.
Grandiose delusions and poor concentration
3.
Outlandish behaviors and inappropriate dress
4.
Nonstop physical activity and poor nutritional intake
4
(Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased
need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's
mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible
symptoms. However, the correct option clearly presents a problem that compromises physiological
integrity and needs to be addressed immediately)
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