The nurse is caring for a client who has a long history of alcohol abuse who is to be discharged tomorrow. Which of the following is most important for the nurse to consider when assisting to create a discharge plan?
1. Referral to a social worker to assist with housing
2. Food tickets to use a...
The nurse is caring for a client who has a long history of alcohol abuse who is to be discharged
tomorrow. Which of the following is most important for the nurse to consider when assisting to
create a discharge plan?
1. Referral to a social worker to assist with housing
2. Food tickets to use at a local food bank
3. Participation in Alcoholic Anonymous (AA) groups
4. Prescription for an antidepressant from the HCP - ANS 3. Participation in Alcoholic
Anonymous (AA) groups
A 28 year-old male client is admitted to the Emergency Department (ED) after a sexual assault.
The client states "I feel so helpless and embarrassed right now." Which of the following nursing
statements best supports the client at this time?
1. "This is not your fault, it is the fault of the person who attacked you"
2. "You sound like you are feeling helpless, I am here to help you today"
3. "You have options and a choice in how we will proceed today"
4. "It is not common for men to experience sexual assault, I am here to help you through this
examination" - ANS 2. "You sound like you are feeling helpless, I am here to help you
today"
A client with aggressive behavior is admitted to the psychiatry unit. What is an example of a
biological factor that may be associated with violent and aggressive behavior?
1. Increased serotonin levels
2. Decreased dopamine levels
3. Prefrontal cortex damage
4. Low levels of testosterone paired with high levels of cortisol - ANS 3. Prefrontal cortex
damage
The nurse is assessing a client admitted to an inpatient psychiatry unit for a manic episode.
When conducting a demographic assessment, which factors put the client at an increased risk
of aggression or violence? Select all that apply.
1. History of violence
2. Male gender
,3. Difficulty expressing or dealing with emotions
4. History of difficulty with anger management
5. Age 14-24 years - ANS 1. History of violence
2. Male gender
5. Age 14-24 years
A client is increasingly agitated. The nurse is completing a risk assessment for the assaultive
stage for anger, aggression or violence. Which of the following client behaviors would indicate
they are at risk of assaulting another person? Select all that apply.
1. Negative or hostile response to limit-setting by the nurse
2. Hyperactivity
3. Need for support of anger from others
4. Intense or avoidant eye contact
5. Verbal abuse, profanity, argumentativeness or threats - ANS 1. Negative or hostile
response to limit-setting by the nurse
2. Hyperactivity
4. Intense or avoidant eye contact
5. Verbal abuse, profanity, argumentativeness or threats
A client with schizoaffective disorder is escalating their maladaptive anger while on an inpatient
psychiatry unit. Which of the following client statements would indicate to the nurse that the
client is at risk of assaulting hospital staff? Select all that apply.
1. "I am so tired of being locked up in this unit if I need to hurt someone to leave I will"
2. "I am not angry it is my right to do what I want"
3. "I feel like I am losing control of my life"
4. "I am being assertive when I say I am fed up with this, not angry"
5. "The other clients feel the same way about the lack of care on the unit" - ANS 1. "I am so
tired of being locked up in this unit if I need to hurt someone to leave I will"
2. "I am not angry it is my right to do what I want"
4. "I am being assertive when I say I am fed up with this, not angry"
A 25 year-old woman is brought to the Emergency Department (ED) after being beaten by her
husband. She is assessed and is not in danger from her injuries at this time. Which of the
following statements, if made by the client, would signal the nurse that she should be
hospitalized? Select all that apply.
1. "I think it would be better if my husband was dead"
2. "I have a best friend who lives in another town"
3. "I think my husband might kill me if I go home"
4. "Sometimes I think that I can't go on anymore"
5. "I know if I go home that I will not have anyone to help me" - ANS 1. "I think it would be
better if my husband was dead"
,3. "I think my husband might kill me if I go home"
4. "Sometimes I think that I can't go on anymore"
5. "I know if I go home that I will not have anyone to help me"
An Emergency Department (ED) nurse is assessing a client with injuries suspicious of intimate
partner violence. Which of the following nursing questions helps to uncover the client's
perceptions of what has happened? Select all that apply.
1. Tell me more about how you have been in the past few days or weeks.
2. Who do you talk to when you feel overwhelmed?
3. How does your living situation with your partner affect your life?
4. Who can you trust?
5. Describe how you are feeling right now. - ANS 1. Tell me more about how you have
been in the past few days or weeks.
3. How does your living situation with your partner affect your life?
5. Describe how you are feeling right now.
A client is seeking assistance at a public health unit. The client states he is suffering from
intimate partner violence. The nurse assesses his safety and perception of what is happening.
Which of the following questions best address the client's situational supports? Select all that
apply.
1. Who do you talk to when you are overwhelmed?
2. Do you belong to a spiritual community?
3. During difficult times in the past, who did you want most to help you?
4. What leads you to seek help now?
5. What would need to be done to resolve this situation? - ANS 1. Who do you talk to when
you are overwhelmed?
2. Do you belong to a spiritual community?
3. During difficult times in the past, who did you want most to help you?
A community health nurse is assessing a client's personal coping skills while working at a
Women's Shelter for victims of intimate partner violence. The client recently moved to the
community from another country and has limited social supports. Which of the following client
statements demonstrate positive coping by the client? Select all that apply.
1. I find that running helps me to think more clearly since entering the shelter
2. In the past, my mother was able to help me through difficult times
3. This time I am going to stay in the shelter until I am ready to move to my own place
4. My culture values family I know I could go back to my community for help
5. I am not sure of what might happen if I go home - ANS 1. I find that running helps me to
think more clearly since entering the shelter
2. In the past, my mother was able to help me through difficult times
3. This time I am going to stay in the shelter until I am ready to move to my own place
, 4. My culture values family I know I could go back to my community for help
The nurse providing discharge teaching to a client after a suicide attempt. The client says "My
life would be better if my mother were dead. Maybe that will happen now." What is the
responsibility of the nurse in this situation?
1. To call the client's mother and make her aware of the comment
2. To ask the client why he feels this way about his mother
3. To notify the healthcare provider (HCP) immediately to assess the situation
4. To ask the client if he has plans to harm his mother - ANS 3. To notify the healthcare
provider (HCP) immediately to assess the situation
The nurse is assessing a client admitted to an inpatient psychiatry unit for severe anxiety. When
conducting a demographic assessment, which factors put the client at an increased risk for
maladaptive expressions of anger? Select all that apply.
1. Diagnosis of dementia or brain injury
2. Puberty and adolescence
3. History of ineffective coping
4. History of violence
5. Diagnosis of borderline, histrionic or antisocial personality disorder - ANS 1. Diagnosis of
dementia or brain injury
2. Puberty and adolescence
3. History of ineffective coping
5. Diagnosis of borderline, histrionic or antisocial personality disorder
Which of the following client actions would alert the nurse that they are in the pre-assaultive
stage of anger, aggression, or violence? Select all that apply.
1. The client is asking the other inpatients if they are unhappy with care
2. The client is hitting, punching and striking object in their room
3. The client is increasingly withdrawn and not talking to the nurse
4. The client is defying the nurse by not taking their medications
5. The client has possession of a pair of scissors in their room - ANS 1. The client is asking
the other inpatients if they are unhappy with care
3. The client is increasingly withdrawn and not talking to the nurse
4. The client is defying the nurse by not taking their medications
A client diagnosed with generalized anxiety disorder (GAD) is taking diazepam. Which of the
following instructions should the nurse give to the client with regards to this medication? Select
all that apply.
1. Consult with the health care provider (HCP) prior to stopping the medication
2. Avoid eating cheese and tyramine-rich foods
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