CA 2 MID Flashcards
Which of the following are appropriate strategies for a client with bulimia?
a. Avoid shopping for large amounts of food
b. Control eating impulses
c. Identify anxiety-causing situations
d. Eat only three meals per day
c. Identify anxiety-causing situations
A female client who’s at high risk for suicide needs close supervision. To best ensure the client’s safety, the nurse should
a. Check on the client frequently at irregular intervals throughout the night
b. Assure the client that the nurse will hold in confidence anything the client says
c. Repeatedly discuss previous suicide attempts with the client
d. Disregard decreased communication by the client because this is common in suicidal clients
a. Check on the client frequently at irregular intervals throughout the night
During postprandial monitoring, a female client with bulimia nervosa tells the nurse, “You can sit with me, but you’re just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice.” What is the nurse’s BEST response?
a. “I trust you not to purge.”
b. “How are you purging and when do you do it?”
c. “Don’t worry. I won’t allow you to purge today.”
d. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”
d. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”
A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, “It felt so wonderful to get high.” Which of the following is the most appropriate response?
a. “If you continue to talk like that, I’m going to stop speaking to you.”
b. “You told me you got fired from your past job for missing too many days after taking drugs all night.”
c. “Tell me more about how it felt to get high.”
d. “Don’t you know it’s illegal to use drugs?”
b. “You told me you got fired from your past job for missing too many days after taking drugs all night.”
The nurse is assigned to care for a suicidal client. Which is the nurse’s highest care priority?
a. Assessing the client’s home environment and relationships outside the hospital
b. Exploring the nurse’s own feelings about suicide
c. Discussing the future with the client
d. Referring the client to a clergy person to discuss the moral implications of suicide
d. Referring the client to a clergy person to discuss the moral implications of suicide
A male client is found, sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should the nurse approach him initially?
a. Enter the room quietly and move beside him to assess his injuries
b. Call for staff back-up before entering the room and restraining him
c. Move as much glass away from him as possible and sit next to him quietly
d. Approach him slowly while speaking in a calm voice, calling his name, and telling him that the nurse is here to help him
d. Approach him slowly while speaking in a calm voice, calling his name, and telling him that the nurse is here to help him
A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
a. “Why didn’t you get someone else to drive?”
b. “Tell me how you feel about the accident.”
c. “I recommend that you attend an Alcoholics Anonymous meeting.”
d. “You should know better than to drink and drive.”
b. “Tell me how you feel about the accident.”
A 25-year-old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?
a. The client will commit to a drug-free lifestyle
b. The client will work with the nurse to remain safe
c. The client will drink plenty of fluids daily
d. The client will make a personal inventory of strengths
b. The client will work with the nurse to remain safe
A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting the neighbor’s dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues?
a. A rigid posture, restlessness, and glaring
b. Depression and physical withdrawal
c. Silence and noncompliance
d. Hyper vigilance and talk of past violent acts
a. A rigid posture, restlessness, and glaring
Client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse?
a. “I’m not addicted to alcohol. In fact, I can drink more than I used to without being affected.”
b. “I only spend half of my paycheck at the bar.”
c. “I just drink to relax after work.”
d. “I know I’ve been arrested three times for drinking and driving, but the police are just trying to hassle me.”
d. “I know I’ve been arrested three times for drinking and driving, but the police are just trying to hassle me.”
A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:
a. Ineffective individual coping related to feelings of guilt
b. Situational low self-esteem related to feelings of loss of control
c. Risk for violence: Self-directed related to impulsive mutilating acts
d. Risk for violence: Directed toward others related to verbal threats
c. Risk for violence: Self-directed related to impulsive mutilating acts
The nurse is aware that which client is at highest risk for suicide?
a. One who appears depressed, frequently thinks of dying, and gives away all personal possessions
b. One who plans a violent death and has the means readily available
c. One who tells others that he or she might do something if life doesn’t get better soon
d. One who talks about wanting to die
d. One who talks about wanting to die
Nurse Benson is explaining the components of the psyche to a group of nursing students, focusing on the role of the superego. How should she describe the function of the superego?
a. It evaluates situations before making decisions.
b. It acts impulsively and lacks a moral framework.
c. It engages in defensive mechanisms to protect the self.
d. It serves as the censoring part of the mind.
d. It serves as the censoring part of the mind.
During a sensitive consultation, Nurse Reynolds discusses options with a wife still living with an abusive spouse. She needs to provide support in a non-judgmental and empowering way. Which statement is the most appropriate for Nurse Reynolds to make?
a. “I have the contact information for a crisis center where you can seek immediate assistance.”
b. “Have you had a chance to talk about this situation with your family?”
c. “Can you help me understand your reasons for staying in this situation?”
d. “Consider the safety benefits of leaving your current situation.”
a. “I have the contact information for a crisis center where you can seek immediate assistance.”
Following the wife’s admission of abuse and her expression of a persistent distaste for sexual activity, Nurse Reynolds needs to classify the described sexual disorder accurately. Which category does this issue fall into?
a. Sexual Desire Disorder
b. Orgasm Disorder
c. Sexual Arousal Disorder
d. Sexual Pain Disorder
a. Sexual Desire Disorder
During a health education session, Nurse Perry explains the characteristics of somatoform disorders to a group of healthcare professionals. Which statement about somatoform disorders is accurate?
a. Symptoms are an expression of psychological conflicts through physical manifestations.
b. Physical symptoms are directly explained by organic causes.
c. Symptoms are a voluntary manifestation of psychological conflicts.
d. Management of somatoform disorders includes specific medical treatments targeted at the symptoms.
a. Symptoms are an expression of psychological conflicts through physical manifestations.
Nurse Peterson is conducting a mental health workshop and begins by defining mental health to ensure all participants have a foundational understanding. How should she explain mental health?
a. The capacity to differentiate reality from illusion.
b. The enhancement and protection of mental health, the prevention of mental disorders, and the comprehensive care and rehabilitation during illness.
c. A state of well-being enabling one to recognize personal abilities, manage everyday stress, and contribute productively.
d. Simply the lack of any mental disorders.
c. A state of well-being enabling one to recognize personal abilities, manage everyday
Nurse Harding is discussing the psychological theories of anxiety during a training session and refers to Freud’s explanation. How did Freud interpret anxiety?
a. It strives to satisfy both the needs for gratification and security.
b. It is a reaction involving the hypothalamic-pituitary-adrenal axis in response to stress.
c. It represents a conflict between the id and superego.
d. It is a learned response to stressors.
c. It represents a conflict between the id and superego.
Nurse Daniels is responding to a 30-year-old male patient who persistently complains of low back pain despite negative test results. Which response is the most appropriate and empathetic way for her to address his concerns?
a. “I understand that you’re in pain. Let’s discuss some strategies to manage your symptoms.”
b. “There’s nothing wrong with you, the tests are negative.”
c. “You should try to ignore the pain and go about your daily activities.”
d. “The pain is probably just in your head since the tests are negative.”
a. “I understand that you’re in pain. Let’s discuss some strategies to manage your symptoms.”
When parents express concerns about their ability to care for a child with maladaptive behaviors, Nurse Thompson needs to identify an appropriate nursing diagnosis. Based on the parents’ apprehensions, which nursing diagnosis is most suitable?
a. Risk for Injury
b. Social Isolation
c. Parental Role Conflict
d. Ineffective Health Maintenance
c. Parental Role Conflict
Nurse Johnson is assessing a 29-year-old male employee who frequently reports low back pain, resulting in many absences from work. Despite extensive testing, all results come back negative. Which somatoform disorder is most likely affecting this patient?
a. Somatoform Pain Disorder
b. Somatization Disorder
c. Hypochondriasis
d. Conversion Disorder
a. Somatoform Pain Disorder
Nurse Jose is formulating nursing diagnoses for a 30-year-old male employee who often complains of low back pain without any positive findings on medical tests. Which of the following would be an inappropriate nursing diagnosis for this client?
a. Altered role performance
b. Altered comfort: pain
c. Impaired social interaction
d. Ineffective individual coping
c. Impaired social interaction
During a home visit, Nurse Reynolds notices potential signs of abuse involving a mother and her child. To further investigate, she needs to ask a sensitive yet direct question. Which of the following questions is most appropriate for her to use?
a. “Do you often discipline your child harshly?”
b. “Why do you think your child has these bruises?”
c. “Can you explain how your child got these injuries?”
d. “Are you hurting your child?”
c. “Can you explain how your child got these injuries?”
In a training discussion about team roles in psychiatric care, Nurse Carter clarifies the specific responsibilities associated with different positions. What accurately describes the role of a technician?
a. Overseeing and coordinating all aspects of a patient’s care.
b. Administering medications to a patient diagnosed with schizophrenia.
c. Providing education about the effects of alcohol.
d. Feeding and bathing a patient in a catatonic state.
b. Administering medications to a patient diagnosed with schizophrenia.
During the initial assessment of a 33-year-old woman admitted for treatment of depression, Nurse Clark is on the lookout for typical symptoms associated with the condition. Based on her understanding of depression, which symptom is Nurse Clark least likely to observe in this patient? (Select all that apply.)
A. Difficulties in making decisions.
B. An increased interest in romantic activities.
C. A family history of depression.
D. Persistent feelings of hopelessness.
B. An increased interest in romantic activities.
On physical assessment of a patient with severe anemia, the nurse would expect to find:
A. Nervousness and agitation
B. Fever and tenting of the skin
C. Systolic murmur and tachycardia
D. Bluish mucous membranes and reddened skin
C. Systolic murmur and tachycardia
Immunization of children with Haemophilus influenzae type B (Hib) vaccine decreases the incidence of which of the following conditions?
A. Bronchiolitis
B. Laryngotracheobronchitis (LTB)
C. Epiglottitis
D. Pneumonia
C. Epiglottitis
Which of the following respiratory conditions is always considered a medical emergency?
A. Asthma
B. Cystic fibrosis (CF)
C. Epiglottitis
D. Laryngotracheobronchitis (LTB)
C. Epiglottitis
Which of the following is the best method for performing a physical examination on a toddler?
A. From head to toe
B. Distally to proximally
C. From abdomen to toes, then to head
D. From least to most intrusive
D. From least to most intrusive
The nurse explains that a ventricular septal defect will allow:
A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis.
C. No shunting because of high pressure in the left ventricle.
D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume.
A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect is:
A. A loud, harsh murmur with a systolic tremor.
B. Cyanosis when crying.
C. Blood pressure higher in the arms than in the legs.
D. A machinery-like murmur.
A. A loud, harsh murmur with a systolic tremor.
The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is blood pressure that is:
A. Higher on the right side.
B. Higher on the left side.
C. Lower in the arms than in the legs.
D. Lower in the legs than in the arms.
D. Lower in the legs than in the arms.
The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is:
A. “He is always hungry.”
B. “He tires out during feedings.”
C. “He is fussy for several hours every day.”
D. “He sleeps all the time.”
B. “He tires out during feedings.”
A mother of an infant diagnosed with Hirschsprung’s disease asks the nurse about the disorder. The nurse plans to base the response on which information?
A. It is a complete small intestinal obstruction.
B. It is a congenital aganglionosis or megacolon.
C. It is a severe inflammation of the gastrointestinal tract.
D. It is a condition that causes the pyloric valve to remain open.
B. It is a congenital aganglionosis or megacolon.
The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child’s record?
A. Watery diarrhea
B. Projectile vomiting
C. Increased urine output
D. Vomiting large amounts of bile
B. Projectile vomiting
The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. Which assessment finding is unassociated with this diagnosis?
A. The presence of stool in the urine
B. Failure to pass a rectal thermometer
C. The passage of currant jelly–like stool
D. Failure to pass meconium in the first 24 hours after birth
C. The passage of currant jelly–like stool
The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child’s temperature. Which method of temperature measurement should be avoided?
A. Rectal
B. Axillary
C. Electronic
D. Tympanic
A. Rectal
The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?
A. Excessive oral secretions
B. Bowel sounds heard over the chest
C. Hiccupping and spitting up after a meal
D. Coughing, wheezing, and short periods of apnea
C. Hiccupping and spitting up after a meal
The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant?
A. Prone position
B. Side-lying position
C. Modified Trendelenburg’s position
D. Infant car seat with the head of the seat in a flat position
B. Side-lying position
A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder?
A. An acute bowel obstruction
B. A condition that causes an acute inflammatory process in the bowel
C. A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
D. A condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel
C. A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
The nurse is assisting a primary health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the primary health care provider palpates the child at McBurney’s point. What response does the nurse expect the child to have during the examination?
A. Pain in the upper right side
B. Pain when extending the leg
C. Pain when the right thigh is drawn up
D. Pain in the lower right side between the umbilicus and the iliac crest
D. Pain in the lower right side between the umbilicus and the iliac crest
A child is diagnosed with lactose intolerance. The child’s mother asks the nurse about the disease. Which statement is the appropriate nursing response?
A. “It is the inability to tolerate sugar found in dairy products.”
B. “It results from the absence of ganglion cells in the rectum.”
C. “It results from increased bowel motility that leads to spasm and pain.”
D. “It is the inability to fully digest the protein part of wheat, barley, rye, and oats.”
A. “It is the inability to tolerate sugar found in dairy products.”
The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which of the following statements made by a parent indicates a correct understanding of the teaching?
A. “I should wash my infant’s buttocks with soap and water every time I change the diaper.”
B. “I will wash with a mild soap and water and dry thoroughly whenever my infant has a bowel movement.”
C. “I should wash my infant’s buttocks with soap before applying a thin layer of oil.”
D. “I will apply baby oil and powder to the creases in my infant’s buttocks.”
A. “I should wash my infant’s buttocks with soap and water every time I change the diaper.”
The nurse is assessing a 3-week-old with suspected bacterial meningitis. Isolation and respiratory precautions have already been initiated. Which clinical assessment by the nurse would warrant immediate intervention?
A. The neonate is irritable.
B. The neonate has a rectal temperature of 100.6° F (38.1°C).
C. The neonate is quieter than usual.
D. The neonate’s respiratory rate is 24 breaths per minute.
D. The neonate’s respiratory rate is 24 breaths per minute.
The parents of a 12-month-old male with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations?
A. “Your child will not receive routine immunizations today.”
B. “Your child will receive the recommended vaccines today; regular immunizations help prevent childhood illnesses.”
C. “Your child is not severely immunocompromised, but I would still be concerned about his receiving them. Let’s not give them today.”
D. “Your child may develop infections if he gets his routine immunizations. Your child will not be immunized today.”
A. “Your child will not receive routine immunizations today.”
Which nursing intervention should take place prior to all vaccination administrations?
A. Document the vaccination to be administered on the immunization record and medical record.
B. Provide the vaccine information statement handout, and answer all questions.
C. Administer the most painful vaccination first, and then alternate injection sites.
D. Refer to the vaccination as “baby shots” so the parent understands the baby will be receiving an injection.
B. Provide the vaccine information statement handout, and answer all questions.
Which assessment is most important after any injury in a child?
A. History of loss of consciousness and length of time unconscious.
B. Serial assessments of level of consciousness.
C. Initial neurological assessment.
D. Initial vital signs and oxygen saturation level.
B. Serial assessments of level of consciousness.
Which statement by an infant’s mother leads the nurse to believe that she needs further education about the nutritional needs of a 6-month-old?
A. “I will continue to breastfeed my son and will give him rice cereal three times a day.”
B. “I will start my son on fruits and gradually introduce vegetables.”
C. “I will start my son on carrots and will introduce one new vegetable every few days.”
D. “I will not give my son any more than 8 ounces of baby juice per day.”
B. “I will start my son on fruits and gradually introduce vegetables.”
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?
A. Administer oxygen.
B. Document the findings.
C. Notify the health care provider.
D. Reassess the respiratory rate in 15 minutes.
B. Document the findings.
A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area?
A. Perianal or rectal area
B. Hemorrhoids or anal fissures
C. Upper gastrointestinal (GI) tract
D. Lower GI tract
C. Upper gastrointestinal (GI) tract
