A nurse suspects child abuse and reports it. The mother becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
As a nurse, I am required by law to report suspected child abuse.
A nurse is assessing an older adult client who lives with her daughter. The older client has several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution
Report the findings to a supervisor.
A client on a mental health unit refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to prevent him from leaving the hosp
False imprisonment
An adolescent client in an emergency department reports being sexually assaulted just prior to admission. Which of the following actions should the nurse assessing the client take?
Ask the client to describe the situation.
A nursing instructor is teaching a group of nursing students which factors to include in an abuse assessment of a client. Which of the following factors should not be included in this teaching?
Socioeconomic status
A nurse in an emergency department is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?
It is not your fault that this happened.
A nursing instructor is teaching a group of nursing students about domestic violence. Which of the following statements by one of the students indicates a need for clarification?
I have heard that abusers think of themselves as important and have high self esteem.
A nurse is assessing a client in an emergency department who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?
Be direct and honest when speaking with the client.
A nurse suspects that an older client is being neglected by a family caregiver. Which of the following statements by the caregiver should the nurse identify as the priority to address?
We buy the prescriptions we can afford.
A nurse is assessing a toddler and notices that he has several bruises. Which of the following actions should the nurse take first?
Ask the parents what caused the bruises.
A nurse in the emergency department is caring for a woman who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident?
Close friend
A nursing instructor is discussing child abuse with a group of nursing students. Which of the following children should the nursing students identify as a potential victim of abuse?
A child whose parents answer questions for the child.
A nurse on a mental health unit is assessing a woman who has experienced intimate partner abuse. The nurse should monitor the woman for which of the following findings?
Self-esteem disturbance
A nurse is setting goals for a client who has terminal lung cancer and is at the end of life. Which of the following are realistic goals?
The client will receive medication to minimize episodes of breakthrough pain.
A home health nurse is providing teaching to the family of a client who has dementia. The nurse should tell the family to expect which of the following manifestations?
Forgetfulness
A client with late-stage Alzheimer's disease is admitted to a mental health unit. During the night shift, the nurse finds the client climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse
Assist the client to the correct room.
A nurse in an emergency room is assessing a client who had a breathing treatment and has Alzheimer's disease. The nurse asks the client if the treatment helped. Which of the following statements by the client should the nurse document as confabulation?
It was good. The Queen of England visited me here.
A nurse on the morning shift is assessing an older adult client who was admitted to a mental health unit yesterday. Which of the following manifestations indicates that the client is experiencing delirium?
The client attempts to climb out of bed and repeatedly states she must get home.
A nurse is caring for a client with dementia on a long-term care unit following the death of her spouse of 50 years. The client states, "I want to go home. My husband is waiting for me to cook dinner." Which of the following responses by the nurse is appr
Tell me what you like to cook for dinner.
A nurse in a health clinic is assessing a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
None of the kids at school like me, and I don't like them either.
A nurse on a mental health unit has assessed several clients who have mental health disorders. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
A client who is taking clozapine and has flu-like manifestations.
During the evening shift, a client in an acute mental health facility commits suicide. Which of the following is the priority intervention for staff following this incident?
Identify cues in the client's behavior that might have warned staff that he was contemplating suicide.
A client in an acute mental health facility comes out of his room and begins to shout angrily at the clients around him. Which of the following actions should the nurse take first?
Speak to the client calmly, giving simple directions.
A client in an acute mental health facility becomes angry and suddenly throws a chair in the dayroom. Which of the following interventions should the nurse perform first?
Attempt to talk the client down.
A female client on an acute mental health unit is upset about lost privileges due to repetitive negative behaviors. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
I understand that you are angry. However, I followed the appropriate protocol.
An older man is brought to the emergency department by his family after being found wandering outside. During the nurse's assessment, the client flinches when his abdomen is palpated yet responds to questions only by nodding his head. Which of the followi
Confusion
A nurse is talking with a client in an acute mental health facility who has a new diagnosis of chronic kidney disease. Which of the following statements by the client should the nurse identify as an indication of anticipatory grieving?
I just can't believe that this dialysis is going to ruin my whole life.
An adolescent female in an acute mental health facility has attention deficit hyperactivity disorder (ADHD). The nurse should expect which of the following findings?
Impulsivity
A school-age child with ADHD is being discharged from an acute mental health facility. The nurse is teaching the parents about atomoxetine. Which of the following instructions should the nurse include in the teaching?
Give the dose in the morning to help prevent insomnia.
A nurse is planning care for a child in an acute mental health facility who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?
Establish a reward system for positive behavior.
A nursing instructor is teaching a group of nursing students about autism. The nursing students demonstrate understanding of autism when they state that they would expect to see manifestations of autism in which of the following clients?
Toddler
A client who is suicidal declines the nurse's request to make a safety contract. Which of the following actions should the nurse identify as the priority?
Assign a staff member to stay with the client at all times.
A client diagnosed with major depressive disorder tells the nurse, "My family would be better off if I were gone." Which of the following is the nurse's priority response?
Are you thinking of harming yourself?
A nurse in an acute mental health facility is assessing a newly admitted adolescent following a suicide attempt. The nurse should determine that which of the following is the priority risk factor for suicide attempt?
Previous suicide attempt
A nurse is talking to a client 2 days after being admitted to an acute mental health facility for treatment of depression. The client leaves group, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of t
Ask the client if she has a plan to commit suicide.
A nurse is admitting a female adolescent following a suicide attempt. The client has a diagnosis of major depressive disorder, anorexia nervosa, and has a history of substance abuse. Which of the following actions is the nurse's priority?
Initiating suicide precautions.
A client on an acute mental health unit has become angry and increasingly aggressive after a phone call. Which of the following actions should the nurse take when interacting with this client?
Use clarification to determine what the client is feeling.
After a family meeting, a client begins to yell and scream at staff members. Which of the following should be the nurse's priority action?
Say to the client, "I can tell that you are upset.
A nurse is assessing an older female client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. The nurse should take which of the following actions to address the safety needs of this client?
Move the client to a room closer to the nurses' station.
At discharge, a nurse on an acute mental health unit is developing a safety plan for a client who is a survivor of violence. Which of the following would the nurse address first?
Recognizing signs of danger
A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when they identify which of the following as the probability that a person will successfully complete suici
Lethality
A nursing instructor is describing uncomplicated grief to a class. Which of the following would the instructor most likely include in the discussion?
Most bereaved persons experience uncomplicated grief.
A nurse is assessing a 45-year-old client who is grieving following the death of her husband eight months ago. The client reports that she has lost 25 lb. and is having difficulty sleeping. Which of the following factors indicate the client is experiencin
The client's husband died eight months ago.
A nurse is caring for a client who has been diagnosed with end-stage lung cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?
The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
A nurse in an acute mental health facility is assessing a client who is experiencing a normal grief reaction following the loss of his spouse. Which of the following findings should the nurse expect?
Insomnia
A nurse is assessing a client who is experiencing grief following the unexpected death of her spouse. Which of the following statements by the client indicates she is experiencing maladaptive grieving
I have started smoking again.
A nurse in an acute mental health facility is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grieving?
A client who is diagnosed with metastatic lung cancer.
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
Increasing feelings of anger.
A nurse is assessing a 30-year-old female in an emergency department. Which of the following statements made by the woman would indicate that she is experiencing a crisis?
I don't understand. I can't seem to function like I usually do.
A client's 5-year-old poodle ran in front of a car and was killed. The client continues to be upset by her pet's death, and she explains to a community counseling center nurse that she can't stop crying because, "My Precious meant the world to me, and now
Situational