A severely anxious patient experiencing headaches, palpitations, and inability to concentrate is admitted to a medical floor. Which nursing intervention would take priority?
A. Encourage the patient to express feelings. B. Discuss alternative coping strategies with the patient. C. Use a distractio...
NURS 322 Final Exam Questions and
Solutions
A severely anxious patient experiencing headaches, palpitations, and inability to
concentrate is admitted to a medical floor. Which nursing intervention would take
priority?
A. Encourage the patient to express feelings.
B. Discuss alternative coping strategies with the patient.
C. Use a distraction, such as having the patient attend group.
D. Sit with the patient, and use a calm but directive approach. ✅D. Sit with the patient,
and use a calm but directive approach.
A patient is exhibiting tension and needs direction to solve problems. Which intervention
would the nurse implement using a behavioral approach?
A. Assess the patient's family history for anxiety disorders
B. Encourage the patient to use deep breathing techniques.
C. Ask the patient to think of a time in the past when
anxiety was manageable.
D. Encourage journal writing to express feelings. ✅B. Encourage the patient to use
deep breathing techniques.
A 17-year-old patient is brought into the emergency department after taking a handful of
lorazepam (Ativan) as a result of a recent breakup with her fiancée. What priority
nursing intervention should the nurse implement first?
A.Discuss patient's feelings about the breakup with her fiancée.
B. Monitor vital signs and note any signs of central nervous system depression
C.Allow the patient time to rest because lorazepam (Ativan) is sedating.
D. Increase fluids and place the patient on close observation. ✅B. Monitor vital signs
and note any signs of central nervous nsystem depression
A client who has been sexually abused tearfully states, "I'm no good now; there is
nothing to live for." The most therapeutic response by the nurse would be:
A."Tell me more about your feelings."
B."I can understand why you feel worthless."
C."Why do you feel there is nothing to live for?"
"You feel this way now because of what has happened." ✅A."Tell me more about your
feelings."
,Before effectively responding to a sexual assault victim in the emergency department, it
is essential that the nurse:
A.Get the client's name and address.
B.Call for assistance from the psychiatrist.
C.Know some myths and facts about rape.
D.Be aware of any personal bias about rape. ✅D.Be aware of any personal bias about
rape.
The nurse is caring for patient with an addictive disorder who is currently drug-free. The
patient is experiencing repeated occurrences of vivid, frightening images and thoughts.
Which term would the nurse use to document this finding?
A. Tolerance
B. Flashbacks
C. Withdrawal
D. Synergistic effect ✅B. Flashbacks
Which patient symptoms should the nurse suspect as related to alcohol withdrawal?
A. Hyper-alert state, jerky movements, easily startled
B. Tachycardia, diaphoresis, elevated blood pressure
C. Peripheral vascular collapse, electrolyte imbalance
D. Paranoid delusions, fever, fluctuating levels of consciousness ✅A. Hyper-alert
state, jerky movements, easily startled
While entering the building, an elementary school nurse observes a person in the
distance emerging from a forest and approaching the school. The person is dressed in
black from head to toe; wearing a backpack; and carrying a long, narrow, dark object.
Which action should the nurse take first?
a. Move to a secure location.
b. Observe the intruder's features.
c. Take note of the intruder's location.
d. Activate the school code for an intruder. ✅a. Move to a secure location.
This scenario presents a potential adventitious crisis in phase 1. The nurse must first
consider safety. After moving to a secure location, the nurse can activate the school's
code for an intruder and describe the intruder to law enforcement.
An adult has had long-term serious medical problems and has just started a new
medication resulting in decreased libido and sexual performance. The adult's spouse
privately says to the nurse, "I don't feel loved anymore. I feel sexual urges, but my
partner is not interested." Select the nurse's therapeutic response.
a. "Tell me about how your partner shows love for you."
, b. "You're describing a scenario that many couples face."
c. "Let's consider some other ways you can satisfy your needs."
d. "I'm glad you are able to talk about and accept your situation." ✅c. "Let's consider
some other ways you can satisfy your needs."
The scenario presents a maturational crisis. Helping the spouse to consider other
options is the nurse's most therapeutic action.
The nurse in a high school meets with small groups of students the day after a school
bus accident resulted in the death of five students. Which comment should the nurse
use to begin the session?
a. "Sometimes life is not fair. Yesterday's tragedy is an example of just how unfair it can
be."
b. "We're grateful that you are safe. Our discussion is to talk about feelings associated
with yesterday's tragedy."
c. "We've had a terrible loss. I also feel your pain. You need to talk about your feelings
associated with the event."
d. "Thank you for coming today. As school leaders, we know it is very important to
respond to yesterday's tragedy." ✅b. "We're grateful that you are safe. Our discussion
is to talk about feelings associated with yesterday's tragedy."
In phase 1 of a crisis, a person faces a conflict or problem that threatens the self-
concept and responds with increased feelings of anxiety. The nurse should first assure
students that they are safe and then specify the reason for the session.
A patient on an acute psychiatric unit removed the cap from the ceiling sprinkler,
resulting in rapid flooding of the unit. After moving patients to a safe area, which action
should the nurse take next?
a. Conduct individual sessions with patients regarding the experience.
b. Increase the volume of overhead music to distract patients from the event.
c. Implement a psychomotor activity to reduce anxiety associated with the event.
d. Lead a group session with patients to discuss feelings associated with the event.
✅d. Lead a group session with patients to discuss feelings associated with the event.
After addressing safety concerns, the nurse should take steps to help patients feel safe
and lower anxiety, such as providing a quiet environment, building rapport, and
acknowledging their crisis experience. A group session will allow patients who are
unable to articulate their feelings to hear from patients who are able to discuss it.
Three weeks after being assaulted by a patient, a nurse develops headaches, insomnia,
and gastrointestinal problems. The nurse has had four absences from work over a 2-
week period. Which action should the nursing supervisor employ?
a. Refer the nurse for counseling and support.
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