NUR 162 Exam 5 - appointments with a rape crisis nurse. At the f...

NUR 162 Exam 5

• A college student, who was nearly raped while out jogging, completes a series of

appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?

• "You've really been helpful. Can I count on you for continued support?"
• "I work out in the college gym rather than jogging outdoors."
• "I'm really glad I didn't go home. It would have been hard to come back."
• "I carry mace when I jog. It makes me come back."

4."I carry mace when I jog. It makes me feel safe and secure."feel safe and secure."

Answer

• "I carry mace when I jog. It makes me feel safe and secure."feel safe and secure."

• Which statement is most accurate regarding the assessment of clients diagnosed with

psychiatric problems?

• Medical history is of little significance and can be eliminated from the nursing

assessment.

• Assessment provides a holistic view of the client, including biopsychosocial aspects.
• Comprehensive assessments can be performed only by advanced practice nurses.
• Psychosocial evaluations are gained by subjective reports rather than objective

observations.Answer

• Assessment provides a holistic view of the client, including biopsychosocial

aspects.

• Which statement regarding nursing interventions would a nurse identify as accurate?
• Nursing interventions are independent from the treatment team's goals.
• Nursing interventions are solely directed by written physician orders.
• Nursing interventions are comprehensive and reflect current clinical nursing

practice

• Nursing interventions are standardized by policies and procedures.

Answer

• Nursing interventions are comprehensive and reflect current clinical nursing

practice

• Which function is exclusive to the advanced practice psychiatric nurse?
• Teaching about the side effects of neuroleptic medications
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• Using psychotherapy to improve mental health status
• Using milieu therapy to structure a therapeutic environment

• Providing case management to coordinate continuity of health services

Answer

• Using psychotherapy to improve mental health status

• The nurse would recognize which acronym as representing problem-orient- ed charting?

1. SOAPIE

2. APIE

3. DAR

4. PQRST

Answer

1. SOAPIE

• Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and

immediately following electroconvulsive therapy (ECT)?

• CIWA scale

2. GGT

3. BMSE

• CAPS scale

Answer

3. BMSE

• Which is being assessed when a nurse asks a client to identify name, date, residential

address, and situation?

• Mood
• Perception
• Orientation

• Affect

Answer

• Orientation
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• Which describes the primary purpose of a registered nurse gathering client information?
• It enables the nurse to modify behaviors related to personality disorders.
• It enables the nurse to make sound clinical judgments and plan appropriate care.
• It enables the nurse to prescribe the appropriate medications.

• It enables the nurse to assign the appropriate Axis I diagnosis.

Answer

• It enables the nurse to make sound clinical judgments and plan appropriate care.

• A nurse on an inpatient psychiatric unit implements care by scheduling client activities,

interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

• Health teacher
• Case manager
• Milieu manager

• Psychotherapist

Answer

• Milieu manager

• 9. The following outcome was developed for a client

Answer "Client will list five personal strengths by the

end of day one." Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

• Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
• Self-care deficit R/T altered thought process
• Disturbed body image R/T major depressive disorder AEB mood rating of 2/10

• Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

Answer

• Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

• 10. How would a nurse prioritize nursing diagnoses? 3 / 4

• By the established goal of care
• By the life-threatening potential
• By the physician's priority of care

• By the client's preference

Answer

• By the life-threatening potential

• A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and

daytime napping. Which is a correctly written and appropriate outcome for this client?

• The client will avoid daytime napping and attend all groups.
• The client will exercise, as needed, before bedtime.
• The client will sleep seven uninterrupted hours by day four of hospitaliza- tion.

• The client's sleep habits will improve during hospitalization.

Answer 3.The client will sleep seven uninterrupted hours by day four of hospitalization.

• 12. The following NANDA-I nursing diagnostic stem was developed for a client on an

inpatient unit

Answer

Risk for injury. Which assessment data most likely led to the development of this problem statement?

• The client is receiving ECT and is diagnosed with Parkinsonism.
• The client has a history of four suicide attempts in adolescence.
• The client expresses hopelessness and helplessness and isolates self.
• The client has disorganized thought processes and delusional thinking.

Answer

• The client is receiving ECT and is diagnosed with Parkinsonism.

• 13. Which response by the instructor most accurately answers the stu- dent's question

regarding how to best develop nursing outcomes for clients?

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