TEST 4: Stress, Crisis, Anger, and Violence

Question 1

The Client Managing Stress
1. The nurse cares for a middle-aged client with a below-the-knee amputation. Which statement
indicates the need for further assessment of the client’s body image?
1. “When I get my prosthesis, I want to learn to walk so I can participate in walkathons.”
2. “I hope to get skilled enough at using my prosthesis to help others like me adjust.”
3. “Whenever I start to feel sorry for myself, I remember that my buddy died in that accident.”
4. “I hope I can handle having a prosthesis, but I’m really wondering what my wife will think.”

Answer 1

The Client Managing Stress
1. 4. The client expressing doubts about his wife’s response to his amputation as well as possible
doubt on his part is still struggling with body image issues. Looking forward to participating in
walkathons and helping others indicates plans for the future that imply an acceptance of his amputee
status. Remembering that his friend died in the accident that caused his amputation indicates that the
client is aware that there was a worse end result to the accident than his amputation.
CN: Psychosocial integrity; CL: Evaluate

Question 2

2. A client demonstrates moderate anxiety regarding a pending medical procedure. The nurse
   should do which of the following to minimize the client’s anxiety about the procedure?
3. Assuring the client that pain is not associated with the procedure.
4. Providing a brief explanation and then doing the procedure quickly.
5. Giving a demonstration of what is to be done.
6. Indicating to the client that it is normal to feel anxious and fearful before such a procedure

Answer 2

2. 2. A short explanation followed by quick completion of the procedure minimizes anxiety. The
      client may be fearful of pain, and assuring him that there will be no pain offers false reassurance. A
      demonstration may cause increased anxiety. Informing the client that his feelings are common
      normalizes anxiety and puts the client more at ease, but it is not the most reassuring approach.
      CN: Psychosocial integrity; CL: Synthesize

Question 3

3. A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about
   blood glucose testing. After the session, the client states, “I can’t be expected to remember all this
   stuff.” The nurse should recognize this response as most likely related to which of the following?
4. Moderate to severe anxiety.
5. Disinterest in the illness.
6. Early-onset dementia.
7. Normal reaction to learning a new skill.

Answer 3

3. 1. Anxiety, especially at higher levels, interferes with learning and memory retention. After the
      client’s anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring.
      Because the client’s illness is a chronic, lifelong illness that severely changes his lifestyle, it is
      unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would
      be the cause of the client’s frustration and lack of memory. The client’s response indicates anxiety.
      Client responses that would indicate lessening anxiety would be questions to the nurse or requests to
      repeat part of the instruction.
      CN: Psychosocial integrity; CL: Analyze

Question 4

4. A client in a general hospital is to undergo surgery in 2 days. He is experiencing moderate
   anxiety about the procedure and its outcome. To help the client reduce his anxiety, the nurse should:
5. Tell the client to distract himself with games and television.
6. Reassure the client that he will come through surgery without incident.
7. Explain the surgical procedure to the client and what happens before and after surgery.
8. Ask the surgeon to refer the client to a psychiatrist who can work with the client to diminish
   his anxiety.

Answer 4

4. 3. An explanation of what to expect decreases anxiety about upcoming events that could be seen
      as traumatic by the client. Distraction, such as with games or television, only decreases anxiety
      temporarily and does not fulfill the client’s need for information about the procedure. Reassurance
      about an uncomplicated outcome is not appropriate; the nurse cannot guarantee that the client will
      come through surgery without problems. Referring the client to a psychiatrist is not indicated for
      moderate, expected preoperative anxiety.
      CN: Physiological adaptation; CL: Synthesize

Question 5

5. Anxiety occurs in degrees, from a level that stimulates productive problem solving to a level
   that is severely debilitating. At a mild, productive level of anxiety, the nurse should expect to see
   which of the following as a cognitive characteristic of mild anxiety?
6. Slight muscle tension.
7. Occasional irritability.
8. Accurate perceptions.
9. Loss of contact with reality.

Answer 5

5. 3. With mild anxiety, perceptions are accurate. Slight muscle tension reflects a motor response.
      Occasional irritability is an emotional response. Loss of contact with reality is a cognitive
      characteristic of severe anxiety.
      CN: Physiological adaptation; CL: Analyze

Question 6

6. As a client’s level of anxiety increases to a debilitating degree, the nurse should expect which
   of the following as a psychomotor behavior indicating a panic level of anxiety?
7. Suicide attempts or violence.
8. Desperation and rage.
9. Disorganized reasoning.
10. Loss of contact with reality.

Answer 6

6. 1. Suicide attempts and violence are psychomotor responses to a panic level of anxiety.
      Desperation and rage are emotional responses. Disorganized reasoning and loss of contact with
      reality are cognitive responses.
      CN: Physiological adaptation; CL: Analyze

Question 7

7. Nursing interventions with an anxious client change as the anxiety level increases. At a lowlevel of anxiety, the primary focus of interventions is on which of the following?
8. Taking control of the situation for the client.
9. Learning and problem solving.
10. Reducing stimuli and pressure.
11. Using tension reduction activities.

Answer 7

7. 2. Mild anxiety motivates the client to focus on issues and resolve them. Therefore, learning
      and problem solving can occur at a mild level of anxiety. Taking control for the client is reserved for
      a near-panic level of anxiety. Severe anxiety interferes with reasoning and functioning. Therefore,
      reducing stimuli and pressure is crucial at a severe level. Tension reduction is appropriate at a
      moderate level to help the client think more clearly and engage in problem solving.
      CN: Physiological adaptation; CL: Analyze

Question 8

8. When coping becomes dysfunctional enough to require the client to be admitted to the hospital,
   the nurse should assess the client for the ability to demonstrate which of the following?
9. Objective and rational problem solving.
10. Tension reduction activities and then problem solving.
11. Anger management strategies with no problem solving.
12. Minimal functioning with new problems developing.

Answer 8

8. 4. Minimal functioning, causing new problems to develop, is a reflection of dysfunctional
      coping. The ability to objectively and rationally problem solve demonstrates adaptive coping.
      Tension reduction activities demonstrate palliative coping. However, such activities alone do not
      solve problems; they must be followed by problem solving. Anger management alone may prevent
      new problems, such as violence toward oneself or others, but it does not solve problems directly. It is
      considered maladaptive coping.
      CN: Physiological adaptation; CL: Analyze

Question 9

9. In addition to teaching assertiveness and problem-solving skills when helping the client cope
   effectively with stress and anxiety, the nurse should also address the client’s ability to:
10. Suppress anger.
11. Balance a checkbook.
12. Follow step-by-step directions.
13. Use conflict resolution skills.

Answer 9

9. 4. Because relationships inherently lead to stress and anxiety, conflict resolution skills are
      essential for solving relationship problems. Dealing with anger is more effective than suppressing it.
      Suppression is a mechanism that avoids the issue rather than solving it. Balancing a checkbook
      involves calculations, not coping skills. Following directions is a passive activity that reflects a lack
      of problem solving by the client.
      CN: Psychosocial integrity; CL: Analyze

Question 10

10. Which client statement indicates that the client has coped effectively with a relationship
    problem?
11. “My wife will be happy to know that I can spend less time at work now.”
12. “My wife and I are talking about our likes and dislikes in activities.”
13. “I can understand how my wife and I see things differently.”
14. “We are really listening to each other about our different views on issues.”

Answer 10

10. 4. The client’s statement that he and his wife listen to each other reflects improved efforts at
       communicating about issues. The other statements provide some insight into the need for better
       communication. However, they are but steps along the way to coping effectively with the problem.
       CN: Psychosocial integrity; CL: Evaluate

Question 11

11. In an ongoing assessment, the nurse should identify the client’s thoughts and feelings about a
    situation in addition to which of the following?
12. Whether the client’s behavior is appropriate in the context of the current situation.
13. Whether the client is motivated to decrease dysfunctional behaviors.
14. Which of the client’s problems have the highest priority.
15. Which of the client’s behaviors necessitates a no-harm contract.

Answer 11

11. 1. Assessment examines the client’s thoughts, feelings, and behaviors within a context.
       Whether the client’s behavior is appropriate for the situation is important assessment data. Setting
       priorities is part of making nursing diagnoses and planning; motivation to change and identifying the
       need for a no harm contract are part of the planning stage.
       CN: Psychosocial integrity; CL: Analyze

Question 12

12. When developing appropriate short-term goals with clients who are inpatients, which of the
    following is most realistic?
13. The client will demonstrate a positive self-image.
14. The client will describe plans for how to get back into school.
15. The client will write a list of strengths and needs.
16. The client will practice assertiveness skills in confronting his mother.

Answer 12

12. 3. Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving
       positive self-esteem would occur over the long term. Going to school involves complex future steps
       to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done
       a self-assessment.
       CN: Psychosocial integrity; CL: Synthesize

Question 13

13. A nurse is counseling a client with cancer who is experiencing anxiety. Which goal will
    provide the best long-term client outcome?
14. Keep follow-up appointments with psychiatrists.
15. Understand medication effects and adverse effects.
16. Take medication as prescribed.
17. Solve problems without help from others.

Answer 13

13. 4. The ultimate outcome is to have the client solve problems by himself, collaborating in his
       own care. Client follow-up with the psychiatrist, while desirable, does not ensure that the client will
       fully comply with treatment or medication. Knowledge of the medication’s effects and adverse effectsand compliance can help the client but alone will not ensure success unless the client knows how to
       address and solve problems without help from others.
       CN: Health promotion and maintenance; CL: Synthesize

Question 14

14. When integrating the concepts underlying the cognitive-behavioral model into a client’s planof care, the nurse should focus on which of the following areas?
15. Substitution of rational beliefs for self-defeating thinking and behaving.
16. Insight into unconscious conflicts and processes.
17. Analysis of fears and barriers to growth.
18. Reduction of bodily tensions and stress management.

Answer 14

14. 1. Substituting rational beliefs is a major goal when using cognitive-behavioral models, which
       focus more on thinking and behaviors than feelings. Unconscious processes are the focus of
       psychoanalytic models. Analysis of fears and barriers to growth is the focus of developmental
       models. Tension and stress are targets of the stress models.
       CN: Psychosocial integrity; CL: Apply

Question 15

15. Which of the following client statements indicates that the client has gained insight into his
    use of the defense mechanism of displacement?
16. “I can’t think about the weekend right now. I’ve got to study for the exam.”
17. “I know I’m not good in sports, but I feel good about my grades.”
18. “Now when I’m mad at my wife, I talk to her instead of taking it out on the kids.”
19. “For years I couldn’t remember being molested; now I know I have to face it.”

Answer 15

15. 3. Displacement refers to a defense mechanism that involves taking feelings out on a less-
       threatening object or person instead of tackling the issue or problem directly. Talking to his wife
       directly reflects insight into the client’s use of the defense mechanism and his ability to overcome it.
       Not thinking about the weekend is suppression. Here, the client is focusing on the issue with the
       highest priority. Focusing on academic rather than athletic achievement is compensation, highlighting
       one’s strengths instead of weaknesses. Not remembering the molestation is repression.
       CN: Psychosocial integrity; CL: Evaluate

Question 16

16. In which of the following situations can a client’s confidentiality be breached legally?
17. To answer a request from a client’s spouse about the client’s medication.
18. In a student nurse’s clinical paper about a client.
19. When a client near discharge is threatening to harm an ex-partner.
20. When a client’s employer requests the client’s diagnosis to initiate medical claims.

Answer 16

16. 3. Legally, there is a duty to warn a potential victim of a client’s intent to harm. Staff can be
       held accountable if the client injures the ex-partner and the staff failed to warn that person. The
       client’s permission is needed to share information with a spouse. Only client initials are used in
       student papers. Release of information is made directly to the client’s insurance company, not to the
       employer.
       CN: Management of care; CL: Apply

Question 17

17. A client is admitted after the police found he had been sleeping in his car for three nights. The
    client says, “My wife kicked me out and is divorcing me. It wasn’t my fault I was fired from work. My
    wife and boss are plotting against me because I am smarter than they are.” He then pounds the table
    and says, “I’m not staying here, and you can’t stop me.” Which of the following should be included in
    the client’s plan of care? Select all that apply.
18. Collateral information from his wife and boss.
19. Anxiety and anger management.
20. Appropriate housing.
21. Divorce counseling.
22. Assault and escape precautions.
23. Suspiciousness and grandiosity issues.

Answer 17

17. 2, 5. The client is showing increased anxiety and anger as well as refusing to stay in the
    hospital, which are immediate and crucial concerns at admission. The client is not likely to give
    permission to talk to his wife and boss at this point. Housing issues and divorce counseling may be
    relevant before discharge, but not initially. Suspiciousness and grandiosity may be relevant after the
    client’s anxiety and anger are under control.
    CN: Management of care; CL: Create

Question 18

18. Which of the following is a crucial goal of therapeutic communication when helping the client
    deal with personal issues and painful feelings?
19. Communicating empathy through gentle touch.
20. Conveying client respect and acceptance even if not all of the client’s behaviors are tolerated.
21. Mutual sharing of information, spontaneity, emotions, and intimacy.
22. Guaranteeing total confidentiality and anonymity for the client.

Answer 18

18. 2. The nurse is required to set limits on inappropriate behavior while conveying respect and
       acceptance of that person. Doing so conveys to the client that he is worthy without posing any harm or
       embarrassment to the client. Touch is a complex issue that must be used cautiously. Touch may be
       misinterpreted or misperceived by a client who has been abused or who has perceptual or thought
       disturbances. Mutual sharing reflects a social friendship, not a therapeutic one. Total confidentiality is
       not desirable. For example, treatment team members and insurance companies need selected
       information to ensure quality services.
       CN: Psychosocial integrity; CL: Apply

Question 19

19. An 18-year-old pregnant college student presented at the prenatal clinic for an initial visit at
    14 weeks’ gestation. The client’s history revealed that when she was 12, she and her mother survived
    a plane crash that killed her father and sister. Since that time, she has taken Prozac (fluoxetine) 20 mg
    orally daily for posttraumatic stress disorder (PTSD) and depression. Her medication was recently
    increased to 40 mg daily because of reports of increased stress and suicide ideation. Which of the
    following side effects of Prozac would the nurse judge to be the greatest risk for the young woman
    and her developing fetus at this stage in her pregnancy?
20. Insomnia.
21. Nausea/anorexia.
22. Headache.4. Decreased libido.

Answer 19

19. 2. Growth of the fetus is important, so nausea and anorexia that would interfere with the young
       woman’s nutrition would cause the most harm to the developing fetus. It could also lead to electrolyte
       imbalance if she did not take in enough fluid. While insomnia could cause problems long-term, this
       side effect could be mitigated through adjustment of the dosing time (earlier in the day) or decrease of
       the dosage to her former 20 mg daily or even every other day dosing of 40 mg since Prozac has a long
       half-life. Headaches are uncomfortable but can be treated with mild analgesics or other treatmentssuch as cold cloths that would not harm the fetus. Decreased libido, while not enjoyable for the client
       or her sexual partner, does not pose any risks for the fetus.
       CN: Pharmacological and parenteral therapy; CL: Analyze

Question 20

20. Which of the following questions or statements should the nurse use to encourage client
    evaluation of his or her own behavior?
21. “I can hear that it’s still hard for you to talk about this.”
22. “So what does this all mean to you now?”
23. “What did you do differently with your coworker this time?”
24. “What will it take to carry out your new plans?”

Answer 20

20. 3. Asking for descriptions of changes in behavior (what the client did differently) encourages
       evaluation. Conveying empathy, such as stating that it is still hard for the client to talk about it,
       encourages data collection. Asking for meaning helps with the nursing diagnosis. Asking the client
       about what her husband said the previous night is part of evaluation.
       CN: Psychosocial integrity; CL: Apply

Question 21

21. With shorter lengths of stay becoming the norm, which statement is true of the stages of the
    nurse-client relationship?
22. Different phases of the relationship involve emphasizing different processes and goals related
    to client needs.
23. Building trust is the most that can be accomplished during the relationship.
24. What can be achieved during the relationship is problem identification and referrals.
25. Teaching new skills becomes the most important aspect of the relationship phases

Answer 21

21. 1. With the shorter lengths of stay, the processes and goals of a particular stage are chosen
       according to the client’s current needs and abilities. Building trust (orientation stage) is a priority
       with psychotic and suspicious clients. It is less crucial for the client ready to work on issues. Making
       referrals (termination stage) is appropriate for all clients regardless of their needs. The other needs
       will be addressed in counseling after discharge. Teaching skills (working stage) is appropriate for
       clients with insight and readiness for change. They may not be appropriate for clients with severe
       psychosis or suspiciousness, especially if denial is present.
       CN: Management of care; CL: Apply

Question 22

22. Even when the client understands problems and is motivated to change, the client may have
    fears about failing. Which of the following interventions is most likely to facilitate change?
23. Reality testing about the need for change.
24. Asking the client about fears that need to be overcome.
25. Teaching new communication skills.
26. Practicing new behaviors with the nurse.

Answer 22

22. 4. Practicing new behaviors builds confidence and reinforces appropriate behaviors. Reality
       testing, asking about fears, and teaching new communication skills are some of the many steps when
       trying out new behaviors.
       CN: Psychosocial integrity; CL: Apply

Question 23

The Client Coping with Physical Illness
23. A mastectomy is recommended for a 68-year-old client diagnosed with breast cancer a week
ago. When approached about giving consent for the mastectomy, the client says, “What is the use in
trying to get rid of the cancer? It will just come back! I can’t handle another thing—having diabetes is
enough. Besides, I’m getting old. It would be different if I were younger and had more energy.” What
should the nurse do?
1. Accept the client’s decision since it is her right to choose to obtain treatment or not.
2. Give the client information about the 5- and 10-year survival rates for breast cancer clients
who underwent mastectomies.
3. Call the chaplain to speak with the client about her hopeless attitude about the future.
4. Explore with the client her feelings about her health problems and proposed surgery

Answer 23

The Client Coping with Physical Illness
23. 4. While the client does have a right to accept or reject treatment, she has not explored her
feelings, her possible mastectomy, or the future. The nurse should assist the client in exploring her
feelings and moving toward a fuller understanding of her options. Giving the client survival rates
indicates that the nurse feels she should have the surgery and negates her fears and concerns. While
the chaplain might be helpful, this step should be done after the client has explored her feelings.
CN: Management of care; CL: Synthesize

Question 24

24. An 18-year-old client is recently diagnosed with leukemia. What is the most appropriate
    short-term goal for the nurse and client to establish?
25. Accepting the client’s death as imminent.
26. Expressing the client’s angry feelings to the nurse.
27. Decreasing interaction with peers to conserve energy.
28. Gaining an intellectual understanding of the illness.

Answer 24

24. 2. Diagnosis of a serious illness would be a shock to anyone but particularly a young person.
       Feelings of anger are normal and should be expressed. Gaining an intellectual understanding of his
       illness would also be necessary, but such learning will not take place if the client’s feelings have not
       been addressed. There is no indication that the client needs to conserve energy because of his
       condition, nor is it clear that death is imminent. Neither situation is likely at the point of first
       diagnosis unless the disease is well advanced, which is not indicated here.
       CN: Management of care; CL: Apply

Question 25

25. The nurse has been asked to develop a medication education program for clients with chronic
    mental illness in the rehabilitation program. When developing the course outline, which of the
    following topics is most important to include?
26. A categorization of many psychotropic drugs.
27. Interventions for common side effects of psychotropic drugs.
28. The role of medication in the treatment of acute illness.
29. Effects of combining common street drugs with psychotropic medication.

Answer 25

25. 2. The psychotropic drugs used to treat chronic mental illnesses have side effects that can lead
       to noncompliance. Therefore, teaching the clients measures to deal with the common side effects
       would be most important. Teaching should be focused on the need for compliance and the specific
       interests of the target audience. Teaching should concentrate on the medications commonly used to
       treat chronic mental illness, not on many psychotropic drugs or those used in acute illness. Such
       topics as the role of medication in the treatment of chronic mental illness and the effects of usingcommon street drugs with psychotropic medication should be discussed after the issue of compliance
       is addressed.
       CN: Health promotion and maintenance; CL: Create

Question 26

26. The primary health care provider recommends that a client have a partial bowel resection
    and an ileostomy. Later, the client says to the nurse, “That doctor of mine surely likes to play big. I’ll
    bet the more he can cut, the better he likes it.” Which of the following replies by the nurse is most
    therapeutic?
27. “I can tell you more about the surgery if you like.”
    “What do you mean by that statement?”
28. “Aren’t you being a bit hard on him? He’s trying to help you.”
29. “Does that remark have something to do with the operation he wants you to have?”

Answer 26

26. 2. When the client seems to be questioning the primary health care provider’s goals, it is best
       for the nurse to present an open statement and ask the client what he means. This technique helps the
       client express his feelings. Telling the client about the surgery is less therapeutic when he is upset.
       Chastising the client and defending the primary health care provider are likely to inhibit
       communication about the client’s needs and feelings. Making assumptions can also interfere with
       communication, especially if the assumption is incorrect.
       CN: Psychosocial integrity; CL: Synthesize

Question 27

27. A client becomes increasingly morose and irritable after being told that she has cancer. She is
    rude to visitors and pushes nurses away when they attempt to give her medications and treatments.
    Which of the following should the nurse do when the client has a hostile outburst?
28. Offer the client positive reinforcement each time she cooperates.
29. Encourage the client to discuss her immediate concerns and feelings.
30. Continue with the assigned tasks and duties as though nothing has happened.
31. Encourage the client to direct her anger at staff members instead of her visitors.

Answer 27

27. 2. When the client has hostile outbursts, it is best for the nurse to help her express her feelings.
       This serves as a release valve for the client. Offering positive reinforcement for cooperation does not
       help the client express herself appropriately. Continuing with assigned tasks ignores the client’s
       feelings and may lead to further escalation. Encouraging the client to direct anger to the staff is
       inappropriate. The client needs to express her feelings appropriately.
       CN: Psychosocial integrity; CL: Synthesize

Question 28

28. Arrangements are made for a member of the colostomy club to meet with a client before
    bowel surgery. Which of the following is accomplished by having a representative from the club visitthe client preoperatively?
29. Letting the client know that he has resources in the community to help him.
30. Providing support for the primary health care provider’s plan of therapy for the client.
31. Providing the client with support and realistic information on the colostomy.
32. Convincing the client that he will not be disfigured and can lead a full life.

Answer 28

28. 3. Preoperative visits and talks with others who have made successful adjustments to
       colostomies are helpful and tend to make the client less fearful of the operation and its consequences.
       Knowing about resources in the community will be helpful as the client approaches discharge.
       Supporting the primary health care provider is less important than supporting the client and giving
       him information. The client will have a change in body image, with disfigurement due to the creation
       of a colostomy. However, the client should be able to lead a full life.
       CN: Management of care; CL: Apply

Question 29

29. The client hospitalized for diagnosis and treatment of atrial fibrillation states to the nurse,
    “Please hand me the telephone. I need to check on my stocks and bonds.” Which of the following
    responses by the nurse is most therapeutic?
30. “You will get more upset if you make that call.”
31. “You have atrial fibrillations. Let’s talk about what that means.”
32. “You really don’t care about the fact that you’re sick, do you?”
33. “Do you realize you have a life-threatening condition?”

Answer 29

29. 2. The nurse must present reality to the client about his condition to help decrease his denial
       about his physical status. By stating the name of the condition and talking about what it means, the
       nurse provides the client with information and conveys concerns about him and a willingness to help
       him understand his illness. It may not be true that the client would be made more upset by the call; the
       news might be good. However, this statement does not provide the client with the reality of his
       condition. Telling the client that he really doesn’t care or asking the client if he realizes that he has a
       life-threatening condition is belittling and may make the client defensive.
       CN: Psychosocial integrity; CL: Synthesize

Question 30

30. The nurse should determine that a client lacks understanding of her acute cardiac illness and
    the ability to make changes in her lifestyle by which of the following statements?
    “I already have my airline ticket, so I won’t miss my meeting tomorrow.”
31. “These relaxation tapes sound okay; I’ll see if they help me.”
32. “No more working 10 hours a day for me unless it’s an emergency.”
33. “I talked with my husband yesterday about working on a new budget together.”

Answer 30

30. 1. Leaving the hospital and immediately flying to a meeting indicate poor judgment by the
       client and little understanding of what she needs to change regarding her lifestyle. The other
       statements show that the client understands some of the changes she needs to make to decrease her
       stress and lead a more healthy lifestyle.
       CN: Psychosocial integrity; CL: Evaluate

Question 31

31. A 45-year-old client has been rehospitalized with a severe exacerbation of lupus that affects
    her central nervous system. Her husband approaches the nurse. He says, “My wife is scaring me. She
    says she does not want to live with this illness anymore. Our kids are grown, and she feels useless as
    a mother and a wife.” Which of the following statements are the most appropriate responses to the
    husband? Select all that apply.
32. “I will have a talk with your wife to see if she is suicidal.”
33. “You need to be strong and optimistic when you are with her.”
34. “I’m glad you shared this with me. I can imagine that this is scary for you.”
35. “I’m sure she will feel differently when we get this episode under control.”
36. “We can talk about what you can say to her that may help.”

Answer 31

31. 1, 3, 5. Suicide is a risk with chronic illnesses. The husband needs validation of his feelings
    and support, as well as suggestions for helping his wife with her concerns. Telling him to be strong
    and optimistic ignores the client’s needs. It is false to assume that the client will no longer be suicidal
    when the lupus is under control.
    CN: Safety and infection control; CL: Synthesize

Question 32

32. The client with kidney stones refuses to eat lunch and rudely tells the nurse to get out of his
    room. Which of the following responses by the nurse is appropriate?
33. “I’ll leave, but you need to eat.”
34. “I’ll get you something for your pain.”
35. “Your anger doesn’t bother me. I’ll be back later.”
36. “You sound angry. What is upsetting you?”

Answer 32

32. 4. The nurse’s best response is one that directly expresses the nurse’s observations to the
       client and offers the client the opportunity to talk about his feelings or concerns to decrease
       somatization (the need to express feelings through physical symptoms). Leaving, offering to provide
       pain medication, and stating that anger does not bother the nurse ignore the client’s needs.
       CN: Psychosocial integrity; CL: Synthesize

Question 33

33. A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety
    disorder (OCD). In helping the client understand her illness, the nurse should respond with which of
    the following statements?
34. “Your ulcerative colitis has made you perfectionistic, and it has caused your OCD.”
35. “There is no relationship at all between your colitis and your OCD. They are separate
    disorders.”
36. “The perfectionism and anxiety related to your obsessions and compulsions have led to your colitis.”
37. “It is possible that your desire to have everything be perfect has caused stress that may haveworsened your colitis, but there’s no proof that either disorder caused the other.”

Answer 33

33. 4. Though ulcerative colitis and OCD have some features in common, and stress can make
       both illnesses worse, there is no definitive cause-effect relationship between ulcerative colitis and
       OCD. Therefore, the only appropriate nursing response would be to acknowledge the effect of stress
       on both illnesses and indicate there is no proof that either illness causes the other.
       CN: Physiological adaptation; CL: Synthesize

Question 34

34. A client receiving dialysis directs profanities at the nurse and then abruptly hangs his head
    and pleads, “Please forgive me. Something just came over me. Why do I say those things?” The nurse
    interprets this as which of the following?
35. Neologism.
36. Confabulation.
37. Flight of ideas.
38. Emotional lability.

Answer 34

34. 4. This type of behavior illustrates emotional lability, which is a readily changeable or
       unstable emotional affect. Neologism is using a word when it can have two or more meanings, or a
       play on words. Confabulation involves replacing memory loss by fantasy to hide confusion; it is
       unconscious behavior. Flight of ideas refers to a rapid succession of verbal expressions that jump
       from one topic to another and are only superficially related.
       CN: Psychosocial integrity; CL: Analyze

Question 35

35. On an oncology unit, the nurse hears noises coming from a client’s room. The client is found
    throwing objects at the walls and has just picked up the phone. She is screaming, “How can God do
    this to me? It is the third type of cancer I’ve had. I’ve gone through all the treatment for nothing.” In
    what order of priority from first to last should the nurse make the following interventions?
36. “Tell me what you are feeling right now.”
37. “Please put the telephone down so we can talk.”
38. “I can hear how upset you are about the cancer.”
39. “I wonder if you would like to talk to a clergyman.”

Answer 35

35.
2. “Please put the telephone down so we can talk.”
3. “I can hear how upset you are about the cancer.”
1. “Tell me what you are feeling right now.”
4. “I wonder if you would like to talk to a clergyman.”
The first priority is a safe environment so the client and nurse are not hurt by the phone. Then, it is
important to acknowledge the client’s anger to help diffuse it. As the client calms down, the nurse can
explore the client’s feeling in more depth. Since the client implies anger at God, a clergy consult may
be appropriate.
CN: Safety and infection control; CL: Analyze

Question 36

36. A client who has had AIDS for years is being treated for a serious episode of pneumonia. A
    psychiatric nurse consult was arranged after the client stated that he was tired of being in and out of
    the hospital. “I’m not coming in here any more. I have other options.” The nurse would evaluate the
    psychiatric nurse consult as helpful if the client makes which of the following statements?
37. “Nobody wants me to commit suicide.”
38. “If I talk about suicide, I’ll be transferred to the psychiatric unit.”
39. “I realize that I really do have more time to enjoy my family and friends.”
40. “I’d probably screw up suicide anyway.”

Answer 36

36. 3. Focusing on enjoying time with family and friends conveys a renewal of hope for the future
       and a decreased risk of suicide. Simply saying that no one wants him to commit suicide does not say
       he doesn’t want to do it. Avoiding a transfer to a psychiatric unit does not mean he is no longer
       suicidal. Fear of not being successful with suicide usually is not a deterrent.
       CN: Reduction of risk potential; CL: Evaluate

Question 37

The Client in Crisis

37. The nurse’s overall goal in planning to assist the client responding to a loss is to:
38. Make sure the client progresses through all of the stages of the grief process.
39. Encourage the client to work to resolve lingering family conflicts.
40. Assist the client to engage in the work associated with the normal grieving process.
41. Allow the client to express anger.

Answer 37

The Client in Crisis
37. 3. Individuals progress through the stages of loss at their own pace. Not everyone experienceseach phase, and no one can be forced to advance to the next stage until ready. The overall goal for
helping the client to work through the pain of loss is to assist the client in processing and engaging in
the pain of loss. This process may involve working on family conflicts and/or anger issues but is not
the primary goal.
CN: Health promotion and maintenance; CL: Create

Question 38

38. The nurse working at the site of a severe flood sees a woman, standing in knee-deep water,
    staring at an empty lot. The woman states, “I keep thinking that this is a nightmare and that I’ll wake up
    and see that my house is still there.” Which of the following crisis intervention strategies are most
    needed at this time? Select all that apply.
39. Ask the client about any physical injuries she may have.
40. Determine if any of her family are injured or missing.
41. Allow the client to talk about her fears, anger, and other feelings.
42. Tell her that groups are being formed at the shelter for flood survivors.
43. Refer her to the shelter for dry clothes and food.
44. Assess her for risk of suicide and other signs of decompensation.

Answer 38

38. 1, 2, 3, 6. The immediate needs for this client are for safety and security, so it is important to
    assess for injuries, safety of her family, suicide risk, and signs of emotional decompensation. Needs
    for food, clothing, and support are important later, after safety and security are addressed.
    CN: Reduction of risk potential; CL: Analyze

Question 39

39. The nurse is assessing a client who has just experienced a crisis. The nurse should first
    assess this client for which of the following behaviors?
40. Effective problem solving.
41. Level of anxiety.
42. Attention span.
43. Help-seeking.

Answer 39

39. 2. During the first phase of crisis, the client exhibits elevated anxiety. A client who can use
       problem-solving capabilities is not in crisis. A shortened attention span is characteristic of the fourth
       phase of crisis. Reaching out to others for help is indicative of the third phase of crisis.
       CN: Management of care; CL: Synthesize

Question 40

40. An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and
    saying that she thinks she is pregnant but does not know what to do. Which of the following nursing
    interventions is most appropriate at this time?
41. Ask the client about the type of things that she had thought of doing.
42. Give the client some ideas about what to expect to happen next.
43. Recommend a pregnancy test after acknowledging the client’s distress.
44. Question the client about her feelings and possible parental reactions.

Answer 40

40. 3. Before any interventions can occur, knowing whether the client is pregnant is crucial in
       formulating a plan of care. Asking the client about what things she had thought about doing, giving the
       client some ideas about what to expect next, and questioning the client about her feelings and possible
       parental reactions would be appropriate after it is determined that the client is pregnant.
       CN: Psychosocial integrity; CL: Synthesize

Question 41

41. A potentially pregnant 16-year-old client says that she has been “hooking up” with a boy she
    considers to be her boyfriend. Which of the following responses should the nurse make first?
42. “You mean you have had sexual intercourse?”
43. “Describe what you mean by hooking up.”
44. “I think we need to talk about what’s involved in sexual intercourse.”
45. “All you have been doing with your boyfriend is hooking up?”

Answer 41

41. 2. Because of the client’s potential pregnancy, the nurse needs to determine exactly what the
       client means by the term “hooking up” by asking the client to describe what she has been doing in
       sexual encounters with her boyfriend. Asking the client if she means sexual intercourse or telling the
       client that they need to talk about sexual intercourse makes an assumption that may or may not be
       appropriate. The nurse needs to determine exactly what the client means by the terms used. Repeating
       the client’s statement does not elicit the necessary information to interpret the client’s statement.
       Additionally, this type of response assumes an understanding of what the client has said.
       CN: Psychosocial integrity; CL: Synthesize

Question 42

42. A 40-year-old client who is quite anxious says that she would “rather die than be pregnant.”
    Which of the following responses by the nurse is most helpful?
43. “Try not to worry until after the pregnancy test.”
44. “You know, pregnancy is a normal event.”
45. “You’re only 40 years old and not too old to have a baby.”
46. “I see you’re upset. Take some deep breaths to relax a little.”

Answer 42

42. 4. Because people in an emotional crisis find it difficult to focus their thinking, the goal is to
       return the client to noncrisis functioning. Pointing out and decreasing the client’s level of anxiety is the
       first step in attaining this goal. Telling an obviously distressed person not to worry is ineffective
       because it ignores the client’s distress and concerns. Although pregnancy is a normal event, and 40
       years of age may not be too old for a pregnancy, these responses also ignore the client’s distress and
       feelings.
       CN: Psychosocial integrity; CL: Synthesize

Question 43

43. On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs
    glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell
    their parents about the friend. When formulating a reply, the nurse should consider which of the
    following?
44. The boys probably fear punishment.
45. Sniffing glue is illegal.
46. The boys’ observations could be wrong.
47. Glue sniffing is a minor form of substance abuse.

Answer 43

43. 1. Telephoning the crisis shelter indicates that the boys are alarmed but are reluctant to talk
       with their parents. The boys may fear that their parents will assume that they have been sniffing glue
       and punish them. The nurse should focus on helping the boys talk with their parents. Although sniffing
       glue is dangerous and potentially lethal, it is not illegal. To prove that the observations are incorrect
       requires an intervention beginning with the boys’ parents. Sniffing glue is included in the Diagnostic
       and Statistical Manual of Mental Disorders, fourth edition, text revised, as inhalant abuse. It is not a
       minor form of substance abuse.
       CN: Management of care; CL: Synthesize

Question 44

44. While teaching a group of volunteers for a crisis hotline, a volunteer asks, “What if I’m not
    sure why someone is calling?” Which of the following statements by the nurse is most helpful?
45. “Ask the caller to tell you why he or she is calling you today.”
46. “Tell the caller to make an appointment at the walk-in crisis clinic.”
47. “Instruct the caller to go to the nearest emergency room.”
48. “Tell the caller to let you speak to anyone else in the house.”

Answer 44

44. 1. The crisis worker needs to use active focusing techniques to determine the crisis-
       precipitating event or the immediate problem. Asking the caller, “Why are you calling today?” or
       “What is the immediate problem?” will assist the caller to focus on the specific need or event. Telling
       the client to make an appointment is inappropriate because the problem might be life threatening.
       Telling the caller to go to the nearest emergency room is precipitous and may be unnecessary. Asking
       to speak to someone else in the home may be futile because the caller might be alone. This action also
       ignores the caller and his or her feelings.
       CN: Management of care; CL: Synthesize

Question 45

45. After teaching a group of students who are volunteering for a local crisis hotline, the nurse
    judges that further education about crisis and intervention is needed when a student states which of the
    following?
46. “Callers to a crisis line use this service when they’re overwhelmed and exhausted.”
47. “People use crisis hotlines when they’re in the most pain and nothing is working for them.”
48. “Most people in crisis will be calling the line once every day for at least a year.”
49. “One benefit is that a person will know how to handle stressful situations better in the future.”

Answer 45

45. 3. The concern that someone may call the crisis hotline every day for a year indicates that
       further understanding about crisis and crisis intervention is needed. A crisis situation is time-limited,
       typically resolving in 4 to 6 weeks if handled effectively. If a person calls the line daily for a year,
       that person has not been properly dealt with or is probably in a highly disorganized state requiring an
       alternative intervention. The nurse needs to further review and clarify the material presented. Callers
       are typically in pain, overwhelmed, and exhausted when they call. A crisis can help an individual
       cope better in the future if he learns to handle the situation.
       CN: Management of care; CL: Evaluat

Question 46

46. A 13-year-old girl, whose family is living in a cult, ran away from the group’s compound to
    her aunt’s house. The aunt brought the girl to the emergency department after finding multiple knife
    cuts in various stages of healing on the girl’s body. She is admitted to the unit because of many
    trauma-related symptoms. The nurse should take which of the following actions? Select all that apply.
47. Ask her to describe her experiences in a discussion group with other teens.
48. Teach her emotion management skills to help her deal with her “normal reactions to an
    abnormal situation.”
49. Assess her for other possible injuries, pregnancy, and sexually transmitted diseases.
50. Teach her ways to control self-destructive behaviors such as suicide attempts, self-mutilation,
    and rage outbursts.
51. Obtain a sample for a urine drug screen and routine urinalysis.
52. Help her process her emotions and memories as she is willing to share these

Answer 46

46. 2, 3, 4, 5, 6. Controlling self-destructive behaviors is a priority, but developing emotion
    management skills and processing emotions and memories are also important. Assessing for injuries,
    pregnancy, STDs, and drugs in her system is important due to the fact that most cults foster sex and
    pregnancy in young teens and often use drugs to achieve compliance from the girls. It is not
    appropriate to ask the client to share her experiences in a group of teens. It could be more damaging
    to the client unless the other teens are also trauma/torture survivors.
    CN: Psychosocial integrity; CL: Synthesize

Question 47

47. A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for which of the following lengths of time?
48. 1 to 2 weeks.
    4 to 6 weeks.
49. 12 to 14 weeks.
50. 24 to 26 weeks.

Answer 47

47. 2. Generally, 4 to 6 weeks is viewed as the length of time a client can tolerate the severe level
       of disturbance of a true crisis. In the first week or two, the client usually is still trying to use normal
       coping skills and support systems. After 6 weeks of continuous crisis, a client is probably becoming
       so physically and emotionally drained that he has sought or has been brought by others for medical or
       psychiatric care.
       CN: Management of care; CL: Apply

Question 48

48. The nurse incorporates the underlying premise of crisis intervention, about providing “the
    right kind of help at the right time,” to achieve which of the following goals initially?
49. Regaining emotional security and equilibrium.
50. Resolution of underlying emotional problems.
51. Development of insight and personal growth.
52. Formulation of more effective support systems.

Answer 48

48. 1. The initial goal in crisis intervention is helping the client regain emotional security and
       equilibrium. Resolution of the underlying emotional problems, development of insight and personal
       growth, and formulation of more effective support systems are goals to address as the crisis subsides.
       CN: Psychosocial integrity; CL: Apply

Question 49

9. The nurse understands that with the right help at the right time, a client can successfully
   resolve a crisis and function better than before the crisis, based primarily on which of the following
   factors?
10. Relinquishment of dysfunctional coping.
11. Reestablishment of lost support systems.
12. Acquisition of new coping skills.
13. Gain of crisis prevention knowledge.

Answer 49

49. 3. Learning new coping skills is the major factor necessary for higher functioning. Better
       coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness
       of how to prevent future crises.
       CN: Psychosocial integrity; CL: Apply

Question 50

50. A client is being discharged after 3 days of hospitalization for a suicide attempt that followed
    the receipt of a divorce notice. Which of the following, if verbalized by the client, indicates to the
    nurse that the client is ready for discharge?
51. A readiness for discharge.
52. Names and phone numbers of two divorce lawyers.
53. A list of support persons and community resources.
54. Emotional stability.

Answer 50

50. 3. The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it
       is important for the client to be able to verbalize information about appropriate support persons and
       community resources and to have this information readily available. Although the client may state that
       she is ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not beappropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.
       CN: Management of care; CL: Evaluate

Question 51

51. A distraught father is waiting for his son to come out of surgery. He accidentally backed the
    car into his son, causing multiple fractures and a serious head injury. Which of the following
    statements by the father should alert the nurse to the need for a psychiatric consultation?
52. “My son will be fine, but I may be charged with reckless driving.”
53. “His mother is going to kill me when she finds out about this.”
54. “I just didn’t see him run behind the car.”
55. “If he dies, there will be nothing for me to do but join him.”

Answer 51

51. 4. The statement about joining the son if he dies indicates potential for self-harm and
       subsequent suicide, always a risk during crisis. Although the father may be charged with reckless
       driving, this is not an indication for a psychiatric consultation. Although the son’s mother may be
       extremely upset and angry about the event, this statement is more likely an overstatement, not a real
       risk. The statement about not seeing the son run behind the car illustrates the father’s attempts at trying
       to process the situation.
       CN: Psychosocial integrity; CL: Evaluate

Question 52

52. A grandson who calls the crisis center expressing concern about his grandmother, who lost
    her husband a month ago, states, “She has been in bed for a week and is not eating or showering. She
    told me that she did not want to kill herself, but it’s not like her to do nothing for herself. She won’t
    even talk to me when I visit her.” The nurse encourages the grandson to bring his grandmother to the
    center for evaluation based on which of the following reasons?
53. The behaviors may reflect passive suicidal thoughts.
54. The behaviors reflect altered role performance.
55. Seeing the grandson and grandmother together will be helpful.
56. Refusing to talk to the grandson alone indicates a major problem.

Answer 52

52. 1. Passive suicidal thoughts, such as a wish to die or giving up on self-care, can be as much of
       a risk as active suicidal ideation (the idea of killing one’s self directly), especially for older clients
       because they commonly lack the means, energy, and motivation for an active suicide attempt. Seeing
       the grandson and grandmother together may help later. Not talking to the grandson and experiencing
       altered role performance may be real issues, but these are not as critical as the risk of indirect
       (passive) suicide.
       CN: Psychosocial integrity; CL: Analyze

Question 53

53. A 16-year-old client who is being seen by the crisis nurse after making several superficial
    cuts on her wrist states that all her friends are siding with her ex-boyfriend and won’t talk to her
    anymore. She says she knows that the relationship is over, but “If I can’t have him, no one else will.”
    Which of the following client problems takes the highest priority?
54. Situational low self-esteem.
55. Risk for other-directed violence.
56. Risk for suicide.
57. Risk-prone health behavior.

Answer 53

53. 2. The threat toward the ex-boyfriend is the most immediate concern now, as the client turns
       her anger toward him instead of herself. Although situational low self-esteem, risk for suicide, and
       risk-prone health behavior are accurate, these problems are less of a concern at this time.
       CN: Safety and infection control; CL: Analyze

Question 54

4. A client who comes to the crisis center in a very distressed state tells the nurse, “I just can’tget over being fired last week. I’ve asked for help. I’ve talked to friends. I’ve tried everything to get
   through this, but nothing is working. Help me!” Which of the following should the nurse use as the
   initial crisis intervention strategy?
5. Referral for counseling.
6. Support system assessment.
7. Emotion management.
8. Unemployment assistance

Answer 54

54. 3. Letting the client express his feelings (emotion management) is essential before trying to
       problem solve about the situation or deciding what kind of referral is appropriate. A referral for
       counseling, assessment of the client’s support system, and unemployment assistance may be
       appropriate after the client’s anxiety is reduced.
       CN: Psychosocial integrity; CL: Apply

Question 55

55. A major role in crisis intervention is getting a client’s significant others involved in helping
    with the immediate crisis as soon as possible. The nurse should determine that the support persons
    are prepared to help when they verbalize which of the following?
56. The name and phone number of the client’s primary health care provider.
57. Emergency resources and when to use them.
58. The coping strategies they are using.
59. Long-term solutions they plan to tell the client to use.

Answer 55

55. 2. During a crisis, support persons demonstrate preparedness to help the client by verbalizing
       the emergency resources available and knowing when to use them. Follow-up medical care may be
       helpful as the crisis subsides. The coping strategies used by the support persons may or may not be
       relevant to the client’s needs and situation. Long-term solutions and advice may or may not be
       appropriate. The focus needs to be on the client’s immediate needs and situation.
       CN: Psychosocial integrity; CL: Analyze

Question 56

56. During the interview at a crisis center, a newly widowed client reveals the wish “to join my
    husband in Heaven.” After the nurse asks the client to sign a no harm contract, which of the following
    statements is appropriate to say next?
57. “Tell me what feelings you have been experiencing.”
58. “Has your husband’s estate been settled yet?”
59. “What was the cause of your husband’s death?”
60. “Do you have children who are willing to help you?”

Answer 56

56. 1. The nurse needs to focus on the client and address her feelings. Talking about her feelings
       helps to decrease the risk of self-harm. Doing so takes precedence over questions about the husband’s
       estate, the cause of death, and her children’s support.
       CN: Psychosocial integrity; CL: Synthesize

Question 57

57. A nurse manager of the Crisis Access Center of a psychiatric facility in a major city notices a
    sudden increase in the number of incoming calls one afternoon. After quickly surveying the call
    sheets, the nurse finds that most callers are very anxious after military aircrafts flew very low over
    the city. Which of the following strategies would be most appropriate in this situation? Select all that
    apply.
58. Instruct the crisis workers to additionally screen callers about where they were on 9/11/01 and
    their memories of that event.
59. Give the crisis workers a list of symptoms of PTSD and techniques for dealing with these
    symptoms.
60. Ask for an emergency meeting with the managers of the inpatient and outpatient services to
    formulate a contingency plan for increased services if needed.
61. Ask the major media outlets in the city to make a scripted public service announcement about
    the possible recurrence of symptoms experienced after the events of 9/11/01.
62. Prepare for a scripted interview with the local media about PTSD symptoms and techniques
    for dealing with these symptoms.
63. Ask the Director of Psychiatric Services to call the military to issue an apology for the flyover.

Answer 57

57. 1, 2, 3, 4, 5. All of the options are correct and in an appropriate sequence of actions except
    for option 6. The flyover is likely to trigger vivid memories and emotions in those living near the city
    related to the tragedy of the Twin Towers on 9/11/01. The severity of the flashbacks will vary in
    degree, just as they did after the original event. Asking the military for an apology will not address
    the caller’s symptoms.CN: Management of care; CL: Synthesize

Question 58

The Client with Problems Expressing Anger
58. A 35-year-old man was experiencing marital discord with his wife of 4 years. When his wife
walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking
help at the local mental health center. Which of these questions should the nurse ask initially to begin
to assess this man’s immediate problem?
1. “Do you feel in control of yourself at this time?”
2. “What did you do to cause your wife to leave?”
3. “In hindsight, how might you have managed this situation differently?”
4. “What led you to come in for help today?

Answer 58

The Client with Problems Expressing Anger
58. 4. Beginning with a broad opening statement that brings out the client’s view of his situation
and reasons for seeking treatment is the most neutral beginning and helps to gain the client’s
perception of events. Blaming the client for his problems is accusatory and nonproductive. A time for
reviewing what could be done differently will come later.
CN: Psychosocial integrity; CL: Apply

Question 59

59. A client is being admitted to a psychiatric outpatient program for counseling for his ongoing
    emotional symptoms. He is asked to rate the severity of his depression, anxiety, and anger. He states,
    “I don’t have any anger any more. I lost my temper once and nearly hurt my wife. I never got angry
    again.” In which order of priority from first to last should the following principles related to anger be
    shared with this client?
60. “You can learn effective ways to discuss anger with others and still maintain control.”
61. “Anger is a natural emotion occurring in all human relationships.”
62. “Holding your anger inside contributes to your depression.”
63. “Unexpressed anger has a negative effect on the human body and mind.”

Answer 59

59.
2. “Anger is a natural emotion occurring in all human relationships.”
4. “Unexpressed anger has a negative effect on the human body and mind.”
3. “Holding your anger inside contributes to your depression.”
1. “You can learn effective ways to discuss anger with others and still maintain control.”
The clients need to understand that anger is a normal emotion, but if not expressed can have
negative effects on the body and mind. Then, the nurse begins to focus on the client’s personal
situation and that holding anger in aggravates his depressive symptoms as well. One focus of
outpatient counseling will be learning safe, effective ways to express anger.
CN: Reduction of risk potential; CL: Analyze

Question 60

60. A female client in an anger management group states, “My doctor tells me I need to get mad
    more often and not let people tell me what to do. Maybe she thinks I should be more aggressive.”
    What information should the nurse incorporate in the response to this client?
61. Denial of anger and lack of assertiveness can be as serious as aggressiveness.
62. Assertive behavior in women is not culturally acceptable.
63. The client has most likely misinterpreted what the primary health care provider said.
64. The client is trying to gain acceptance by the group.

Answer 60

60. 3. It is unlikely that the primary health care provider would imply that the client should be
       more aggressive. Denial of anger with passive, unassertive behavior and the aggressive expression of
       anger are dysfunctional behavior patterns. Gender-based stereotypes are not conducive to mental
       health, and deeming assertive behavior in women as culturally unacceptable interferes with the goal
       of developing assertiveness skills. Group acceptance should not be based on whether a client is
       demonstrating assertive or aggressive behavior.
       CN: Psychosocial integrity; CL: Apply

Question 61

61. The father of a solider who was killed 2 days ago is admitted after a serious suicide attempt.
    He is medically stable and has signed a no harm contract. During a talk with the nurse, he says,
    “Terrorism and war are holding me and the whole world hostage. It’s so unfair. I’d rather be dead thanlive alone in constant fear.” Which of the following nursing interventions are important in the next few
    days? Select all that apply.
62. Discussing effective ways to express justifiable anger.
63. Teaching stress management and relaxation techniques.
64. Identifying community groups for relatives of military personnel.
65. Recommending an antiwar advocacy group.
66. Strategizing about ways to increase a personal sense of security.

Answer 61

61. 1, 2, 3, 5. Dealing with anger, stress, and anxiety; identifying resources and support groups;
    and increasing a sense of safety and security are appropriate interventions at this time. However,
    recommending an antiwar advocacy group may or may not be appropriate, even much later in the
    client’s recovery.
    CN: Psychosocial integrity; CL: Synthesize

Question 62

62. In developing a plan of care for a client who has had previous episodes of angry verbal
    outbursts, the nurse plans to take an educational approach to the problem. Arrange the following steps
    the nurse should take from first to last.
63. Assisting the client to recognize the early cues that he is angry.
64. Helping the client identify triggers for his anger.
65. Practicing with the client appropriate ways to express his anger.
66. Identifying alternate ways to express his anger.

Answer 62

62.
2. Helping the client identify triggers for his anger.1. Assisting the client to recognize the early cues that he is angry.
4. Identifying alternate ways to express his anger.
3. Practicing with the client appropriate ways to express his anger.
Angry clients may not realize what makes them angry and the cues that their behavior is becoming
out of control. The nurse should first help the client identify what triggered the anger. Once the cause
of the anger and cues to the loss of control are discovered, the nurse should assist the client in
identifying safe and appropriate alternative expressions of anger and then practice those techniques
prior to facing a real anger-producing situation.
CN: Psychosocial integrity; CL: Synthesize

Question 63

63. The treatment team recommends that a client take an assertiveness training class offered in
    the hospital. Which of the following behaviors indicates that the client is becoming more assertive?
64. The client begins to arrive late for unit activities. When asked why he’s late, he says, “Because
    I feel like it!”
65. The client asks the nurse to call his employer about his insurance.
66. The client asks his roommate to put away his dirty clothes after telling the roommate that this
    bothers him.
67. The client follows the nurse’s advice of asking his doctor about being passive-aggressive.

Answer 63

63. 3. By requesting that the roommate respect his rights (asking the roommate to put the dirty
       clothes on the floor away after telling him that this bothers him), the client is asserting himself.
       Arriving late is commonly passive resistance and thus not an indicator that the client is becoming
       assertive. Asking the nurse to call is dependent behavior. Although asking the doctor is more
       assertive, the client is relying on the nurse’s direction to do so.
       CN: Psychosocial integrity; CL: Analyze

Question 64

64. Which of the following physiologic responses should the nurse expect as unlikely to occur
when a client is angry?
1. Increased respiratory rate.
2. Decreased blood pressure.
3. Increased muscle tension.
4. Decreased peristalsis.

Answer 64

64. 2. Blood pressure, as well as respiratory rate and muscle tension, increases during anger
       because of the autonomic nervous system response to epinephrine secretion. Peristalsis also
       decreases.
       CN: Physiological adaptation; CL: Apply

Question 65

65. Which of the following responses to anger from others should the nurse expect as common inclients?
66. Increased self-esteem.
67. Feelings of invulnerability.
68. Fear of harm.
69. Powerlessness.

Answer 65

65. 3. Fear of harm is a common response to anger in clients who lack coping skills and
       assertiveness. Decreased self-esteem is common because most clients are aware that they have
       difficulty in responding to anger effectively. Although anger may provide an initial feeling of strength
       and invulnerability, this is rarely a sustained response. Powerlessness more commonly leads to anger,
       rather than resulting from it.
       CN: Psychosocial integrity; CL: Apply

Question 66

66. When planning the care of a client experiencing aggression, the nurse incorporates the
    principle of “least restrictive alternative,” meaning that less restrictive interventions must be tried
    before more restrictive measures are employed. Which of the following measures should the nurse
    consider to be the most restrictive?
67. Tension reduction strategies.
68. Haloperidol (Haldol) given orally.
69. Voluntary seclusion or time-out.
70. Haloperidol given intramuscularly.

Answer 66

66. 4. When given intramuscularly, haloperidol is considered most restrictive because it is
       intrusive and a client usually does not receive the drug voluntarily. Oral haloperidol is considered
       less restrictive because the client usually accepts the pill voluntarily. Tension reduction strategies and
       voluntary seclusion are considered less restrictive because they are not intrusive and the client
       usually consents to their use.
       CN: Safety and infection control; CL: Apply

Question 67

67. As an angry client becomes more agitated while talking about his problems, the nurse decides
    to ask for staff assistance in taking control of the situation when the client demonstrates which of the
    following behaviors?
68. Swearing about his wife’s behaviors when discussing marital problems.
69. Picking up a pool cue stick and telling the nurse to get out of his way.
70. Making a fist and pounding loudly on the table.
71. Coming out of his room instead of staying in time-out.

Answer 67

67. 2. Asking the staff for assistance is appropriate when the client demonstrates behaviors that
       involve the direct threat of violence. Holding a stick and telling the nurse to move is the most direct
       threat of violence. Swearing and pounding on a table may be disturbing, but these actions are less of a
       threat. Coming out of his room may indicate noncompliance with directions. However, further
       assessment is needed to determine whether this behavior was a direct threat of violence.
       CN: Management of care; CL: Analyze

Question 68

68. The nurse is advising a client with schizophrenia about what to do when she begins to get
    agitated. The client has been compliant with taking her medications and has worked with clinic staff
    on dealing with her illness and recognizing when she is becoming agitated. Indicate the order from
    first to last in which the nurse should suggest the following actions be taken.
69. “Take your oral lorazepam (Ativan).”
70. “Take your oral haloperidol (Haldol).”
71. “Remove yourself to a quiet environment.”
72. “Tell trusted people that you are becoming upset.”

Answer 68

68.
3. “Remove yourself to a quiet environment.”
4. “Tell trusted people that you are becoming upset.”
1. “Take your oral lorazepam (Ativan).”
2. “Take your oral haloperidol (Haldol).”
Since external stimuli can greatly contribute to agitation, the nurse should teach the client that the
first step is to go to a quiet area, then enlist the help of others, and finally take medication. Taking the
lorazepam first of the two medications would help decrease anxiety quickly, thus diminishing
agitation. If the lorazepam is not successful, the client could take the oral haloperidol to help clear the
client’s thoughts and decrease agitation.
CN: Management of care; CL: Synthesize

Question 69

69. When a client is about to lose control, the extra staff who come to help commonly stay at adistance from the client unless asked to move closer by the nurse who is talking to the client. Which
    of the following best explains the primary rationale for staying at a distance initially?
70. The client is more likely to act out if there is an audience, even additional staff.
71. The nurse talking to the client makes the decisions about other staff actions.
72. The client is likely to perceive others as being closer than they are and feel threatened.
73. When the extra staff is visible, the client is less likely to regain self-control.

Answer 69

69. 3. The client who is about to lose control is experiencing a high degree of anxiety or agitation,
       which alters the client’s ability to perceive reality. Initially, the client may feel threatened by the
       presence of others. A client who is out of control is not thinking about having an audience. Although
       the nurse with the client who is about to lose control is generally the one giving directions, this is not
       a rationale for staying at a distance. When seeing extra staff, the client may or may not be able to gain
       self-control.
       CN: Safety and infection control; CL: Apply

Question 70

70. When preparing to use seclusion as an alternative to restraint for a client who has not yet lost
    control, the nurse expects to use a room with limited furniture and no access to dangerous articles.
    What should the nurse also consider as critical for the safety of the client?
71. A security window in the door or a room camera.
72. Lights that can be dimmed from outside the room.
73. A staff member to stay in the room with the client.
74. A doctor’s prescription for the seclusion before it is initiated.

Answer 70

70. 1. When using seclusion, the safety of the client is paramount. Therefore, staff must be able to
       see the client in seclusion at all times, such as through a security window in the door or with a room
       camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is
       not critical for the client’s safety. Having one staff member stay in a room alone with a potentially
       violent client is unsafe. A doctor’s prescription for seclusion can be obtained before or after it is
       initiated.
       CN: Safety and infection control; CL: Synthesize

Question 71

71. The nurse is required initially to restrain all four of a client’s extremities. For which of the
    following reasons should the nurse anticipate the need to add a full-length restraint blanket?
72. The client states that restraints are tight and uncomfortable.
73. The staff want extra protection for themselves.
74. The client is at risk for injury from fighting the restraints.
75. Staff assessment reveals that the client will feel more secure under the blanket

Answer 71

71. 3. A full-length restraint blanket is added when the client is at risk for injury from fighting the
       restraints. The increased degree of restriction is justified only when the risk of client injury increases.
       Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements
       that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the
       restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate
       protection for the staff.
       CN: Safety and infection control; CL: Apply

Question 72

72. Which of the following is the top priority for the client who is placed in restraints?
73. Monitoring the client every 15 minutes.
74. Assisting with nutrition and elimination.
75. Performing range-of-motion exercise for each limb, one at a time.
76. Changing the client’s position every 2 hours.

Answer 72

72. 1. Safety of the client and staff is the utmost priority. Therefore, the client must be monitored
       closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury.Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and
       changing the client’s position every 2 hours are important after the safety of the client and staff is
       ensured by close, frequent monitoring.
       CN: Safety and infection control; CL: Synthesize

Question 73

73. According to hospital protocol, after a client is restrained, the staff meet and discuss the
    restraint situation. In addition to sharing feelings and offering support, what should the nurse identify
    as the long-term goal?
74. Providing feedback to each other on how procedures were handled.
75. Comparing the perceptions of the various staff members.
76. Deciding when to release the client from restraints.
77. Improving the staff’s use of restraint procedures.

Answer 73

73. 4. The long-term goal of the debriefing after restraining a client is to improve aggression
       management procedures so that prevention of aggression improves and the frequency of restraint use
       decreases. Providing feedback and comparing perceptions are single aspects that would eventually
       lead to the ultimate goal of improving aggression management procedures. When a client can be
       released from restraints is not immediately predictable.
       CN: Management of care; CL: Synthesize

Question 74

The Client with Interpersonal Violence
74. A client was brought to the unit and admitted involuntarily. During visiting the next day, the
client’s brother demands that the client be released immediately. The brother says he might have to
hurt staff if the unit door is not opened. In which order of priority from first to last should the
following nursing actions be implemented?
1. Call security officers to the unit for the protection of all on the unit.
2. Calmly restate to the client and his brother that the client cannot be released without a primary
health care provider’s prescription.
3. Quietly ask the other clients and visitors to move to another area of the unit with a staff
member.
4. Ask the client’s brother to leave the unit quietly when he repeats his demands.

Answer 74

The Client with Interpersonal Violence
74.
2. Calmly restate to the client and his brother that the client cannot be released without a primary
health care provider’s prescription.
4. Ask the client’s brother to leave the unit quietly when he repeats his demands.
3. Quietly ask the other clients and visitors to move to another area of the unit with a staff
member.
1. Call security officers to the unit for the protection of all on the unit.
The first step is to calmly present the reality that the client cannot be released at this time. Next,
the brother should be asked to leave the unit quietly. When he does not, protecting the other clients
and visitors is essential for their safety. (The staff member can help them process what is happening
on the unit.) Calling security to the unit is a last resort when less restrictive measures have not
worked. Calling them, before setting limits with the brother and giving him a choice of actions, will
likely escalate the situation. Security can legally escort the brother off the unit and hospital grounds.
CN: Safety and infection control; CL: Create

Question 75

which of the following should the nurse use as the most important indicator of goal achievement
before discharge?
1. Acknowledgment of her angry feelings.
2. Ability to describe situations that provoke angry feelings.
3. Development of a list of how she has handled her anger in the past.
4. Verbalization of her feelings in an appropriate manner.

Answer 75

75. 4. Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive
       method of coping that reduces the chance that the client will act out these feelings toward others. The
       client’s ability to verbalize her feelings indicates a change in behavior, a crucial indicator of goal
       achievement. Although acknowledging feelings of anger and describing situations that precipitate
       angry feelings are important in helping the client reach her goal, they are not appropriate indicators
       that she has changed her behavior. Asking the client to list how she has handled anger in the past is
       helpful if the nurse discusses coping methods with the client. However, based on this client’s history,
       this would not be helpful because the nurse and client are already aware of the client’s aggression
       toward others.CN: Safety and infection control; CL: Evaluate

Question 76

76. A client is admitted to the psychiatric hospital for evaluation after numerous incidents of
    threatening others, angry outbursts, and two episodes of hitting a coworker at the grocery store where
    he works. The client is very anxious and tells the nurse who admits him, “I didn’t mean to hit him. He
    made me so mad that I just couldn’t help it. I hope I don’t hit anyone here.” To ensure a safe
    environment, the nurse should first:
77. Let other clients know that he has a history of hitting others so that they will not provoke him.
78. Put him in a private room and limit his time out of the room to when staff can be with him.
79. Tell him that hitting others is unacceptable behavior and ask him to tell a staff member when he
    begins feeling angry.
80. Obtain a prescription for a medication to be administered to decrease his anxiety andthreatening behavior.

Answer 76

76. 3. The nurse must clearly address behavioral expectations, such as telling the client that hitting
       is unacceptable, and also provide alternatives for the client, such as letting staff members know when
       he begins to feel angry. Making others responsible for the client’s behavior or isolating the client in
       his room is inappropriate because it does not include the client in managing his behavior. Although
       medication may be helpful, this action does not give the client responsibility for his behavior and is
       not warranted at this time.
       CN: Safety and infection control; CL: Synthesize

Question 77

77. A client loses control and throws two chairs toward another client. What should the nurse do
    next?
78. Ask the client to go to the quiet area and talk about the behavior.
79. Administer an oral tranquilizer and prepare for a show of determination.
80. Process the incident with the client and discuss alternative behaviors.
81. Call for assistance to restrain the client and administer an intramuscular tranquilizer.

Answer 77

77. 4. The client is in the crisis phase of the assault cycle. Therefore, the nurse must act
       immediately, using restraints and an intramuscular tranquilizer to prevent injury to others or further
       property damage. It is too late to ask the client to go to a quiet area to talk because the client’s
       behavior is past the triggering phase. Giving the client an oral tranquilizer and preparing for a show
       of determination are nursing interventions used in the escalation phase. Processing the incident with
       the client and discussing alternative behaviors are interventions used in the postcrisis phase.
       CN: Safety and infection control; CL: Synthesize

Question 78

78. A client with a history of self-mutilation and substance abuse begins talking about memories
    of torture and ritual abuse that ended 15 years ago. To her knowledge, no others were or are being
    abused by the parents. To assist the client to recover from such torture and abuse, the nurse should
    suggest which of the following options ? Select all that apply.
79. Dealing with ambivalent feelings toward her parents.
80. Planning a confrontation with her parents.
81. Determining alternatives to self-destructive behaviors.
82. Filing criminal charges against her parents.
83. Developing safe ways to deal with her rage and guilt.

Answer 78

78. 1, 3, 5. Survivors of torture and ritual abuse typically have intense feelings, including mixed
    emotions about the abusers, anger, rage, and guilt. With self-destructive behavior, they need ways to
    handle these urges, such as dealing with ambivalent feelings, determining alternatives to self-
    destructive behaviors, and developing safe ways to deal with rage and guilt. Confrontation with the
    abusers is not necessarily appropriate. Filing criminal charges is not likely due to the statute of
    limitations.
    CN: Psychosocial integrity; CL: Synthesize

Question 79

79. A woman who was raped in her home was brought to the emergency department by her
    husband. After being interviewed by the police, the husband talks to the nurse. “I don’t know why she
    didn’t keep the doors locked like I told her. I can’t believe she has had sex with another man now.”
    The nurse should respond by saying:
80. “Let’s talk about how you feel. Maybe it would help to talk to other men who have been through this.”
81. “Maybe the doors were locked, but the man broke in anyway.”
82. “Your wife needs your support right now, not your criticism.”
83. “It was not consensual sex. Let’s see if your wife was physically injured.

Answer 79

79. 1. The nurse should respond to the husband’s needs and concerns and should offer support.
       Protecting or defending the wife against his criticism ignores the husband’s needs.
       CN: Psychosocial integrity; CL: Synthesize

Question 80

80. A young man makes an appointment to see the psychiatric nurse at the Employee Assistance
    Program of a large corporation because his female boss is sending him provocative e-mails and
    making seductive remarks on his voice mail at home. The nurse informs him about corporate
    workplace violence guidelines, and he agrees to work with corporate security on the issue. What
    should the nurse do next?
81. Refer the client to his boss’s supervisor to file a report.
82. Suggest the client contact human resources to request a job transfer.
83. Ask the client about his reactions to this situation.
84. Report the incident to the client’s coworkers who are at risk for similar harassment.

Answer 80

80. 3. It is important to know the client’s reactions in order to plan appropriate interventions.
       Until the client’s reactions are known, it is premature to suggest a job transfer, file a report to his
       boss’ supervisor, or alert his coworkers.
       CN: Management of care; CL: Synthesize

Question 81

81. A 75-year-old woman was brought to the crisis center by her husband. The husband reports
    that his wife has been in shock and anxious since her purse was stolen outside of their home. The
    woman blames herself for being robbed, is worried about her stolen wallet and credit cards, and is
    afraid to go home. The nurse should do which of the following? Select all that apply.
82. Request a prescription for lorazepam (Ativan) to decrease her anxiety.
83. Encourage her to talk about the robbery and her feelings.
84. Discuss what changes at home would help her feel safe.
85. Investigate if she has physical injuries from the robbery.
86. Ask her what she thinks she could have done to prevent the robbery.

Answer 81

81. 2, 3, 4. After the impact of a crime, the client’s most important needs are for physical safety
    and emotional security. There is no indication that the client has a severe level of anxiety; therefore,
    lorazepam is not indicated. Asking her how she could have prevented the robbery implies that she
    could be at fault.
    CN: Psychosocial integrity; CL: Synthesize

Question 82

82. A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise
    the friends and relatives of the victim to do during the early stages of the recovery process? Select all
    that apply.
83. Keep in contact with other family and friends.
84. Attend memorial or religious services.
85. Use relaxation techniques and physical activities.
86. Speak out publicly about the impact of the loss.
87. Attend community meetings with others who have lost loved ones.

Answer 82

82. 1, 2, 3, 5. Receiving support from family, friends, other survivors, and community services is
    generally helpful after such events. Relaxation and participation in activities help manage stress
    reactions. Speaking out publicly may or may not be helpful later in the recovery process but may
    actually hinder recovery in the early stages.
    CN: Psychosocial integrity; CL: Synthesize

Question 83

Managing Care Quality and Safety
83. When the client is involuntarily committed to a hospital because he is assessed as being
dangerous to himself or others, which of the following rights are lost?
1. The right to access healthcare.
2. The right to send and receive uncensored mail.
3. Freedom from seclusion and restraints.
4. The right to leave the hospital against medical advice.

Answer 83

Managing Care Quality and Safety
83. 4. When a client is committed involuntarily, the right to leave against medical advice is
forfeited. All the other rights are preserved unless there is further court action or a case of imminent
danger to self or others (hitting staff, cutting self).
CN: Management of care; CL: Apply

Question 84

84. The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an
    aggression management program. Evaluation of such a program would be based primarily on which
    of the following indicators?
85. Fewer client injuries during restraint procedures.
86. A reduction of complaints by clients’ relatives.
87. Fewer staff injuries during restraint procedures.
88. A reduction in the total number of restraint procedures.

Answer 84

84. 4. The primary goal of an aggression management program is to prevent violence. This goal is
       evidenced by a reduction in the total number of restraint procedures used or needed. Although fewer
       client and staff injuries are important, these goals are secondary to prevention. Reduction in the
       number of complaints by clients’ relatives is affected by more variables than just restraint procedures.
       CN: Management of care; CL: Evaluate

Question 85

85. A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her
    injuries is complete and she is ready for discharge. To ensure the woman’s safety and security prior to
    discharge, the nurse should do which of the following? Select all that apply.
86. Determine the current location of the ex-boyfriend.
87. Ask if she plans to see the ex-boyfriend again.
88. Provide information on resources and a safety plan.
89. Ensure that she has a safe place to stay after discharge.
90. Obtain consent to send her emergency department records to her family primary health care
    provider.

Answer 85

85. 1, 2, 3, 4. The crucial interventions involve safety and support. Asking for consent is a health
    privacy issue, not a safety issue, and is not essential to the discharge process.
    CN: Safety and infection control; CL: Synthesize

Question 86

86. Jail staff asked for a mental health evaluation of a 21-year-old female arrested on charges of
    prostitution after she stabbed herself with a fork and woke from nightmares in fits of rage. The
    evaluation revealed that she was kidnapped and held from ages 8 to 16 by a convicted child
    pornographer. She said she never contacted her family after her release from captivity. The nurse
    should do the following in what order of priority from first to last?
87. Initiate suicide precautions and a no harm contract.
88. Ask the client if she wishes to contact her family while hospitalized.
89. Offer empathy and support and be nonjudgmental and honest with her.
90. Encourage safe verbalizations of her emotions, especially anger.

Answer 86

86.
1. Initiate suicide precautions and a no harm contract.
3. Offer empathy and support and be nonjudgmental and honest with her.
4. Encourage safe verbalizations of her emotions, especially anger.
2. Ask the client if she wishes to contact her family while hospitalized.
Safety is a priority after the client stabbed herself. A survivor of trauma/torture needs empathy,
support, honestly, and a nonjudgmental stance from the nurse. Then the client is more willing to learn
safe ways to express feeling, especially anger. It will be the client’s decision if she wants to contact
her family and, if so, under what conditions. She would need extensive preparation before any contact
with her family.
CN: Safety and infection control; CL: Synthesize

Question 87

87. The nurse is planning care for a group of clients. Which client should the nurse identify as
    needing the most assistance in accepting being ill?
88. An 8-year-old boy who alternately cries for his mother and is angry with the nurse about being
    hospitalized after a bike accident.
89. A 32-year-old woman diagnosed with depression related to lupus erythematosus who
    discusses her medication’s adverse effects with the nurse.
90. A 45-year-old man who just suffered a severe myocardial infarction and talks to the nurse
    about concerns regarding resuming sexual relations with his wife.
91. A 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to
    wear an oxygen mask even though poor oxygenation makes her confused.

Answer 87

87. 4. The 60-year-old woman is acting in a way that worsens her physical and mental condition
       because she does not want to be sick. The 8-year-old child is acting normally for someone his age
       who is unexpectedly hospitalized. The cooperation demonstrated by the client with lupus and the
       client who had a myocardial infarction indicates a level of acceptance of their illnesses and of their
       role as being ill.
       CN: Management of care; CL: Analyze

Question 88

8. The nurse judges that a client is ready to be released from seclusion and restraints when the
   client demonstrates which of the following behaviors?
9. Is adequately sedated.
10. Struggles less against the restraints.
11. Stops swearing and yelling.
12. Shows signs of self-control.

Answer 88

88. 4. The client is ready to be released from restraints when he shows signs of self-control,
       decreased anxiety and agitation, reality orientation, mood stabilization, increased attention span, and
       judgment. Adequate sedation, struggling less against restraints, and not swearing and yelling are notadequate signs of being calm and in control.
       CN: safety and infection control; CL: Evaluate

Question 89

89. Despite education and role-play practice of restraint procedures, a staff member is injured
    when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse
    should address which of the following about the injured member?
90. The emotional responses may be similar to those of other crime victims.
91. The member is likely to resign after experiencing such an injury.
92. Legal action against the client will take time and energy.
93. The member must debrief with the assaultive client before returning.

Answer 89

89. 1. Being injured by a client can result in emotional responses similar to those of other crime
       victims. A resignation after being injured is relatively rare. Legal action against the client is
       sometimes discussed but rarely initiated. Debriefing with the client may be inappropriate or
       unnecessary to resolve the situation.
       CN: Management of care; CL: Synthesize

Question 90

90. A nurse calls the unit manager to report that her purse has been stolen from the locked break
    room. The nurse says she thinks she knows which of the staff stole the purse. Which of the following
    actions by the nurse manager would be appropriate? Select all that apply.
91. Confront the person the nurse suspects stole the purse.
92. Call hospital security to initiate an investigation.
93. Ask the nurse to document all the facts related to the stolen purse.
94. Alert nursing administration that a staff’s purse has been stolen.
95. Ask other staff to report any suspicious activity they may have observed.

Answer 90

90. 2, 3, 4, 5. It is appropriate for the nurse manager to initiate a security investigation and ask the
    nurse to document all the facts about the missing purse. Alerting nursing administration is required.
    Seeking information from other staff will help with the investigation. It is inappropriate to confront
    any possible suspects while the investigation is ongoing.
    CN: Management of care; CL: Analyze

Question 91

91. A nurse’s ex-boyfriend enters the unit and states, “If I can’t have her, then no one will.”
    Hospital security escorts him out of the building and warned him not to return. The unit manager held
    a staff meeting to confirm that which of the following workplace violence policies and procedures
    will be implemented? Select all that apply.
92. Give a quick overview of the hospital’s workplace violence policies and procedures.
93. Offer counseling for the nurse threatened by her ex-boyfriend.
94. Work with security and the nurse to initiate workplace precautions related to the ex-boyfriend.
95. Ask security to help the nurse understand how to initiate a protective order against her ex-
    boyfriend.5. Ask the nurse to take a leave of absence until her ex-boyfriend is notified of the protective
    order.

Answer 91

91. 1, 2, 3, 4. National guidelines exist for managing workplace violence. Unit staff, hospital
    administration, and hospital security personnel develop and enforce the resulting policies. These
    include training all staff about workplace violence, processes for reporting of such violence, and
    counseling for the staff victim. Protecting staff and clients may include posting the ex-boyfriend’s
    picture at employee entrances and a protective order initiated by the nurse. With these policies and
    procedures in place, it is counterproductive to ask the nurse to take a leave of absence.
    CN: Management of care; CL: Analyze