A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the rst
component of a safety plan?
INCORRECT
Developing a code to use when it is time to leave is important to protect the safety of the family members. However, this it is not the rst component of
a safety plan.
• Identify signs of escalation of violence.
CORRECT
It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the rst
component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.
Have a predetermined place to go in the event of violence.
INCORRECT
Selecting a predetermined place to go in the event of violence is an essential part of the safety plan. However, it is not the rst component of the safety
plan.
Keep a hidden packed bag of necessities.
INCORRECT
Keeping a hidden packed bag of necessities will make it easier for the client when out of the home. However, it is not the rst component of the safety
plan.
, RN Mental Health Online Practice 2019 B with NGN CLOSE
Que2loaded
Question: 2 of 69 CORREC T Time Elapsed:
Pause Remaining:
PAUSE
00:02:00
08:20:00
FLAG
A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following
therapeutic nursing interventions is the priority?
INCORRECT
The nurse should encourage the child to express feelings in order to acknowledge them. However, another action is the priority.
Support the child's attendance at an assertiveness training group.
INCORRECT
The nurse should promote attendance at an assertiveness training group. However, another action is the priority.
Assist the child to perform relaxation breathing.
INCORRECT
The nurse should assist the child to perform relaxation breathing. However, another action is the priority.
• Reduce environmental stimuli.
CORRECT
The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-
escalate the behavior and prevent injury.
, 00:02:31
08:20:00
FLAG
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions
should the nurse include in the plan?
INCORRECT
The nurse should include a liquid supplement for a client who is below their ideal body weight and might not be able to eat solid foods at rst or might
need the additional nutrition to gain weight.
• Identify the client's trigger foods.
CORRECT
The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to
the food.
Allow the client at least 1 hr for each meal.
INCORRECT
The nurse should limit the client's meal times to about 30 min to prevent putting excessive focus on food.
Weigh the client at bedtime each day.
, RN Mental Health Online Practice 2019 B with NGN CLOSE
Que4loaded
Question: 4 of 69 CORREC T Time Elapsed:
Pause Remaining:
PAUSE
INCORRECT
The nurse should weigh the client immediately after they wake up and void and prior to oral intake. The nurse should weigh the client daily for the rst
week and then three times per week.
00:03:38
08:20:00
FLAG
A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates
acceptance of her illness?
CORRECT
The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
"I am going to stop paying my bills since I won't be around much longer."
INCORRECT
The client is verbalizing hopelessness and demonstrating the grieving stage of depression. This does not indicate acceptance.
"I wish you would go take care of somebody who actually needs you."
INCORRECT
The client is expressing anger, which is a behavioral response to grief. This does not indicate acceptance.
"I am sure I'm going to be able to continue to care for myself without help."
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