NUR 213 - Exam 3 with Verified Solutions
1. 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 sud-
denly lifts, it is likely that
the client may have made
the decision to harm him-
self or herself. Suici...
NUR 213 - Exam 3 with Verified Solutions
1. 3 A moderately depressed client who was hospi-
talized 2 days ago suddenly begins smiling and
(pt who is moderately reporting that the crisis is over. The client says
depressed and has only to the nurse, "I'm finally cured." How should the
been in the hospital 2 nurse interpret this behavior as a cue to modify
days is unlikely to have the treatment plan?
such a dramatic cure.
When a depression sud- 1.
denly lifts, it is likely that Suggesting a reduction of medication
the client may have made
the decision to harm him- 2.
self or herself. Suicide Allowing increased "in-room" activities
precautions are neces-
sary to keep the client 3.
safe) Increasing the level of suicide precautions
4.
Allowing the client off-unit privileges as needed
2. 1 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
3. 3 A female victim of a sexual assault is being seen
in the crisis center. The client states that she
, NUR 213 - Exam 3 with Verified Solutions
(trash response irl still feels "as though the rape just happened yes-
though) terday," 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?"
4. 3 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.
, NUR 213 - Exam 3 with Verified Solutions
Admitting the client to a seclusion room where all
potentially dangerous articles are removed
5. 1 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 cher-
ished 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.
6. 4 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 de-
pressed."
3.
"You will feel better once your medication begins
to work."
, NUR 213 - Exam 3 with Verified Solutions
4.
"You sound very upset. Are you thinking of hurting
yourself?"
7. 2 3 5 A client is admitted with a recent history of severe
anxiety following a home invasion and robbery.
(Reliving an event, During the initial assessment interview, which
experiencing emotional statement by the client should indicate to the
numbness (facing possi- nurse the possible diagnosis of posttraumatic
ble death), and having stress disorder? Select all that apply.
flashbacks of the event
(seeing the same face 1.
everywhere) are all com- "I'm afraid of spiders."
mon occurrences with
posttraumatic stress dis- 2.
order. The statement "I'm "I keep reliving the robbery."
afraid of spiders" relates
more to having a phobia. 3.
The statement "I have to "I see his face everywhere I go."
wash my hands over and
over again many times" 4.
describes ritual compul- "I don't want anything to eat now."
sive behaviors to de-
crease anxiety for some- 5.
one with obsessive-com- "I might have died over a few dollars in my pock-
pulsive disorder. Stating et."
"I don't want anything to
eat now" is vague and 6.
could relate to numerous "I have to wash my hands over and over again
conditions) many times."
8. 4 The nurse assesses a client with the admitting
diagnosis of bipolar affective disorder, mania.
(Mania is a mood char- Which client symptoms require the nurse's imme-
acterized by excitement, diate action?
euphoria, hyperactivity,
excessive energy, de- 1.
creased need for sleep, Incessant talking and sexual innuendoes
and impaired ability to
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