NUR 162 Exam 5
1. 7. A college student, who was nearly raped while out jogging, completes a series of
appointments with a rape crisis nurse. At the final session, which client statement most clearly
suggests thatthe goals of crisis intervention have been met?
1. "You've really been helpful. Can I count on you for continued support?"
2. "I work out in the college gym rather than jogging outdoors."
3. "I'm really glad I didn't go home. It would have been hard to come back."
4. "I carry mace when I jog. It makes me come back."
4."I carry mace when I jog. It makes me feel safe and secure."feel safe and secure."
Answer
4. "I carry mace when I jog. It makes me feel safe and secure."feel safe and secure."
2. 1. Which statement is most accurate regarding the assessment of clients diagnosed with
psychiatric
problems?
1. Medical history is of little significance and can be eliminated from the nursing
assessment.
2. Assessment provides a holistic view of the client, including biopsychosocial aspects.
3. Comprehensive assessments can be performed only by advanced practice nurses.
4. Psychosocial evaluations are gained by subjective reports rather than objective
observations.
Answer
2. Assessment provides a holistic view of the client, including biopsychosocial
aspects.
3. 2. Which statement regarding nursing interventions would a nurse identify as accurate?
1. Nursing interventions are independent from the treatment team's goals.
2. Nursing interventions are solely directed by written physician orders.
3. Nursing interventions are comprehensive and reflect current clinical nursing
practice
4. Nursing interventions are standardized by policies and procedures.
Answer
3. Nursing interventions are comprehensive and reflect current clinical nursing
practice
4. 3. Which function is exclusive to the advanced practice psychiatric nurse?
1. Teaching about the side effects of neuroleptic medications
,2. Using psychotherapy to improve mental health status
3. Using milieu therapy to structure a therapeutic environment
4. Providing case management to coordinate continuity of health services
Answer
2. Using psychotherapy to improve mental health status
5. The nurse would recognize which acronym as representing problem-orient- ed charting?
1. SOAPIE
2. APIE
3. DAR
4. PQRST
Answer
1. SOAPIE
6. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and
immediately following electroconvulsive therapy (ECT)?
1. CIWA scale
2. GGT
3. BMSE
4. CAPS scale
Answer
3. BMSE
7. Which is being assessed when a nurse asks a client to identify name, date, residential
address, and
situation?
1. Mood
2. Perception
3. Orientation
4. Affect
Answer
3. Orientation
,8. Which describes the primary purpose of a registered nurse gathering client information?
1. It enables the nurse to modify behaviors related to personality disorders.
2. It enables the nurse to make sound clinical judgments and plan appropriate care.
3. It enables the nurse to prescribe the appropriate medications.
4. It enables the nurse to assign the appropriate Axis I diagnosis.
Answer
2. It enables the nurse to make sound clinical judgments and plan appropriate care.
9. 8. A nurse on an inpatient psychiatric unit implements care by scheduling client activities,
interacting
with clients, and maintaining a safe therapeutic environment. These actions reflect which role of
the nurse?
1. Health teacher
2. Case manager
3. Milieu manager
4. Psychotherapist
Answer
3. Milieu manager
10. 9. The following outcome was developed for a client
Answer
"Client will list five personal strengths by the
end of day one." Which correctly written nursing diagnostic statement most likely generated the
development of this outcome?
1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
2. Self-care deficit R/T altered thought process
3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt
Answer
1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
11. 10. How would a nurse prioritize nursing diagnoses?
, 1. By the established goal of care
2. By the life-threatening potential
3. By the physician's priority of care
4. By the client's preference
Answer
2. By the life-threatening potential
12. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and
daytime
napping. Which is a correctly written and appropriate outcome for this client?
1. The client will avoid daytime napping and attend all groups.
2. The client will exercise, as needed, before bedtime.
3. The client will sleep seven uninterrupted hours by day four of hospitaliza- tion.
4. The client's sleep habits will improve during hospitalization.
Answer
3.The client will sleep seven uninterrupted hours by day four of hospitalization.
13. 12. The following NANDA-I nursing diagnostic stem was developed for a client on an
inpatient unit
Answer
Risk for injury. Which assessment data most likely led to the development of this problem
statement?
1. The client is receiving ECT and is diagnosed with Parkinsonism.
2. The client has a history of four suicide attempts in adolescence.
3. The client expresses hopelessness and helplessness and isolates self.
4. The client has disorganized thought processes and delusional thinking.
Answer
1. The client is receiving ECT and is diagnosed with Parkinsonism.
14. 13. Which response by the instructor most accurately answers the stu- dent's question
regarding how to
best develop nursing outcomes for clients?
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