1.A nurse educator is presenting information about the nursing process to a class of

1.A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

• Procedures used to implement client care
• Sequence of steps used to meet the client’s needs
• Activities employed to identify a client’s problem
• Mechanisms applied to determine nursing goals for the client

2.A nurse on the medical-surgical unit tells other staff members, “That client can just wait for the lorazepam; I get so annoyed when people drink too much.” What does this nurse’s comment reflect?

• Demonstration of a personal bias
• Problem solving based on assessment
• Development of client acuity to set priorities
• Consideration of the complexity of client care

3.A teenager begins to cry when talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? TC

• Sitting quietly with the client
• Telling the client that crying is not helpful
• Suggesting that the client play a board game
• Recommending how the client can change this situation

4.After being medicated for anxiety, a client says to a nurse, “I guess you are too busy to stay with me.” How should the nurse respond? TC

• “I’m so sorry, but I have to see other clients”
• “I have to go now, but I will come back in 10 minutes” ( offering self)
• “You’ll be able to rest after the medicine starts working”
• “You’ll feel better after I’ve made you more comfortable”

5.A physician is admitted to the psychiatric unit of a community hospital. The client, who was restless, loud, aggressive, and resistive during the admission procedure, states, “I will take my own blood pressure.” What is the nurse’s most therapeutic response? TC

• “Right now you are just another client”
• “If you would rather, I’m sure you will do it correctly”
• “I will get the attendants to assist me if you do not cooperate”
• “I am sorry, but I cannot allow that because I must take your blood

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6.What is the most important tool a nurse brings to the therapeutic nurse-client relationship?

• Oneself and a desire to help
• Knowledge of psychopathology
• Advanced communication skills
• Years of experience in psychiatric nursing
• A 6-year-old child is diagnosed with type 1 diabetes. Considering the child’s cognitive

developmental level, which explanation of the illness is most appropriate? TC

• “Diabetes is caused by not having any insulin in your body”
• “Diabetes will require you to take insulin shots for the rest of your life”
• “You will be taught how to give yourself insulin now that you have diabetes”
• “Taking insulin for your diabetes is like getting new batteries for your superhero toys”
• “But you don’t understand” is a common statement associated with adolescents. What is the

nurse’s best response when hearing this? TC

• “I don’t understand what you mean”
• “I do understand; I was a teenager once too”
• “It would be helpful to understand; let’s talk” (paraphrasing, offering self)
• “It’s you who should try to understand others”
• After a therapy session with a health care provider in the mental health clinic, a client tells

the nurse that the therapist is uncaring and impersonal. What is the nurse’s best response? TC

• “Your therapist is really very good”
• “I hope that the rest of the staff is caring”
• “The therapist is there to help you; try to cooperate”
• “You have strong feelings about your therapy session and your therapist( f)eelings
• What is the priority nursing objective of the therapeutic psychiatric environment for a

confused client?

• Assist the client to relate to others
• Make the hospital atmosphere more home-like
• Help the client become accepted in a controlled setting
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