A nurse's sibling happily says, "I want to introduce you to my fianc�. We're getting married in 6 months." The nurse has encountered the fianc� in a clinical setting and is aware of the fianc�'s diagnosis of schizophrenia. What is the nurse's best respons
Answer: d. Despite personal misgivings, the nurse must maintain the fianc�'s confidentiality.
A patient has been disruptive to the therapeutic milieu for 2 days. A certified nursing assistant says to the nurse, "We need to seclude this patient because this behavior is upsetting everyone on the unit." Considering patients' rights, how should the nu
Answer: b. The scenario offers no indication that the patient is dangerous or out of control; therefore, less restrictive interventions should be employed. The nurse has a responsibility to provide guidance to the certified nursing assistant.
A day-shift nurse contacts a nurse scheduled for the night shift at home and says, "Our unit is full, and there are eight patients in the emergency department waiting for a bed." The night-shift nurse replies, "Thanks for telling me. I am calling in sick.
Answer: a. Fidelity is the ethical principle of maintaining loyalty and commitment to the patient. The nurse in this situation is not maintaining commitment to patients by refusing to work the shift. It is not, however, illegal for a nurse to call off for
In a staff meeting at an inpatient mental health facility for individuals, the administrator announces that psychiatric technicians will now be supervised by the milieu director rather than by nurses. What is the nurse's best action?
a. Confer with collea
Answer: d. Institutional policies and practices do not absolve an individual nurse of responsibility to practice on the basis of professional standards of nursing care. State nurse practice acts specify that assistive personnel must work under a nurse's s
A colleague tells the nurse, "I have not been able to sleep for the past 3 days. I feel like a robot." What is the nurse's best action?
a. Direct the colleague to leave the facility immediately.
b. Observe the colleague closely for evidence of impaired pr
Answer: d. Sleep deprivation causes impaired practice, which jeopardizes patient safety. The colleague's comments indicate that impairment is likely. The nurse should confer with the supervisor to determine the appropriate action.
1. A mature, professional couple plans a large wedding in a city that is 100 miles from their home. Which response is most likely to be associated with this experience?
a. Distress
b. Eustress
c. Acute stress
d. Depersonalization
Answer: b. Eustress is beneficial stress that will help the couple to focus, problem solve, and successfully plan their wedding.
A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful?
a. The student reports improv
Answer: a. Yoga and other physical activities can be effective ways to manage stress. These activities deepen breathing, relieve muscle tension, and can elevate levels of the body's own endorphins, which induces a sense of well-being.
An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, 133and insomnia. The adult's spouse says, "I've walked on eggshells for 5 years, never knowing when something else
Answer: d. The scenario suggests that the spouse has experienced the effects of long-term stress. When stress is prolonged, the body stays alert. Chemicals produced by the stress response can have damaging effects on the body, causing physical diseases. A
A veteran of the war in Afghanistan tells the nurse, "Every day, something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life, but I can't." What is the nu
Answer: a. The veteran has high risk for posttraumatic stress disorder (PTSD). When PTSD is untreated or undertreated, painful repercussions often occur, particularly marital problems, unemployment, heavy substance abuse, and suicide. The highest priority
A patient diagnosed with dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff nurse's comment should prompt the nursing supervisor to intervene?
a. "I have never taken
Answer: c. Although dissociative identity disorder can be a very interesting diagnosis, the nurse should avoid focusing more on one patient at the expense of others.
Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike. The adult replies, "I can't go because I don't have any hiking shoes." Unconsciously, this person is concerned about difficulty with blood glucose management during strenuous
Answer: b. Rationalization refers to justifying an action to satisfy the listener.
Four adult patients describe frightening events that resulted in panic levels of anxiety/fear. Which patient's report most clearly indicates a reasonable fear response?
a. "I saw a large spider crawling along my kitchen wall."
b. "I was at the mall when a
Answer: b. Although all of these situations may produce some level of fear or anxiety, the correct response presents a scenario of imminent, specific danger.
A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the
Answer: d. The student is demonstrating projection, as evidenced by not taking responsibility for his or her own behavior and blaming the instructor for a perception of failing. In the correct answer, the instructor avoids a defensive response and reinfor
Select the best example of altruism.
a. After recovering from a gunshot wound, a police officer attends a local support group.
b. After recovering from open-heart surgery, an individual plays tennis three times a week.
c. An individual who received a live
Answer: c. Altruism is a health defense mechanism in which emotional conflicts and stressors are addressed by meeting the needs of others. With altruism, the person receives gratification either vicariously or from the response of others.
A disaster relief nurse has just arrived to help efforts after a tornado that destroys a town. Which approach would be most appropriate when talking with survivors?
a. Provide active listening.
b. Help the survivors generate possible solutions.
c. Help th
Answer: d. People who have just experienced a disaster such as a tornado will most likely be experiencing severe or panic levels of anxiety. People at this level would benefit most from short, clear instructions. The other options are more appropriate for
A patient at a general medical clinic tells the nurse, "I have so many ailments that I need to see six different doctors. None of them has discovered what is really wrong with me." Which comment should the nurse offer next?
a. "Let's review all the medica
Answer: a. Safety is the nurse's first concern. One serious risk associated with doctor-shopping is medication interactions and duplicate medications.
A nurse in an outpatient medical clinic talks to a patient with a long history of malingering and doctor-shopping. The patient continues to express complaints of multiple problems. Select the nurse's best comment to the patient.
a. "The treatment team bel
Answer: b. It's important for the nurse to convey compassion and support to the patient but without reinforcing the symptoms. Case management can help to limit health care costs. Seeing the patient at regular intervals can instill security and avoid frant
A patient in the emergency department was seen for the third time in a month with complaints of tremors and paresthesia in the lower extremities. Neurological functional disorder was diagnosed. While preparing for discharge, the patient says, "Now I'm hav
Answer: b. A paresthesia is a tingling or pricking sensation. Conversion disorder (functional neurobiological symptom disorder) usually involves weakness or paralysis, abnormal movement, swallowing or speech difficulties, seizures or attacks, and sensory
A patient has been identified as having a somatoform disorder. Which of the following should the nurse do when interacting with the patient?
a. Ignore feelings to avoid promoting progression of symptoms.
b. Redirect conversation away from feelings but sho
Answer: b. Nurses should avoid emphasizing feelings but should continue to show interest in the patient. Ignoring feelings or symptoms completely could result in missing a serious medical issue. Frequent use of benzodiazepines is not recommended, but pati
Which disorder would the nurse suspect when a person takes their child from doctor to doctor and from hospital to hospital with a variety of intentionally induced symptoms?
a. Illness anxiety disorder
b. Functional neurological disorder
c. Factitious diso
Answer: c. People with factitious disorder imposed by another may do things to cause symptoms or illness in another person. They will often go from provider to provider or hospital to hospital. The motivation is for the attention, caring, and sympathy the
A young adult has reported heavy use of alcohol and prescription drugs since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the nurse presents reality while demonstrating compassion?
a. "I know you must feel self
Answer: d. The correct response recognizes the power of addiction but presents the reality of the consequences of continued use.
The nurse at a local clinic reviews phoned-in requests from patients for prescription refills. As the nurse confers with the health care provider about which prescription refill requests should be authorized, which refill request should be considered firs
Answer: c. Lorazepam is a benzodiazepine. Sudden withdrawal from this class of medications has medical complications, including the possibility of death; hence this refill request has priority.
A patient tells the nurse, "After many years, I finally quit smoking. Now I use e-cigarettes only." Which is an appropriate response?
a. "Using e-cigarettes is now more socially acceptable than using traditional cigarettes."
b. "Congratulations on quittin
Answer: b. The nurse should educate the patient. E-cigarettes are advertised as safe; however, they contain nicotine as well as other hazardous chemicals.
A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide first to this patient?
a. Guidance that the prescription should not be
Answer: c. All of the options are correct, but safety is the nurse's first concern. Marijuana is a psychoactive substance. Effects include euphoria, sedation, perceptual distortions, and hallucinations; therefore, driving or operating machinery may be haz
A nurse teaches a patient with alcohol use disorder about a new prescription for naltrexone (ReVia, Vivitrol). Which comment by the patient indicates the teaching was effective?
a. "This medicine will stop my cravings for alcohol."
b. "I should take this
Answer: c. Naltrexone (ReVia, Vivitrol) reduces the desired pleasant feelings related to alcohol or opioid intake and helps to reduce drug cravings. It is part of a total program for maintaining sobriety.