NUR 325 ATI Quiz questions
- A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no
idea what i am going to do. I cannot even think right now". Which of the following actions should the nurse take?
A-Identify other housing options and sources of transportation B- notify the facility chaplain to request scheduling an appointment c- confirm that everything will be alright because belongings can be replaced d- d-maintain eye contact with client and summarize the client's feelings
Answer e- this demonstrates therapeutic communication. during the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available.
Maintaining eye contact demonstrates support, empathy, and advocacy.
- do not offer false hope, instead focus on the feelings of the client and his unique response to
- it can be overwhelming to the client to think about housing and transportation and they are
the crisis -you should help the client identify sources of support ( do not do it for them or presume what is best
immediate needs but right now the nurse should focus on the feelings of the client
- A nurse is assessing a client who is experiencing chronic stress. Which of the following
findings should the nurse expect?a- Hypotension b- viral infection c- increased energy d- increased cognitive awareness Answer B-viral infection because chronic stress can cause a decreased immune response which leads to viral or bacterial infections
-the nurse should expect to find the client hypertensive due to increased cardiac tone from the response to chronic stress
- you would expect to find decreased energy and decreased memory and ability to learn
- A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is
distressed after an insulin injection. Which of the following play activities should the nurse 1 / 3
recognize is therapeutic in helping the child deal with the injection?
a- a needless syringe and a doll b- a video game c- a story book about a child who has diabetes
d- a period of play in the playroom Answer a- this a therapeutic activity for a child because they will allow the child to act out feelings of anger and helplessness
-a video game is a distraction, the activity book does not provide an outlet for working out the feelings that a child is unable to verbalize, playing in the playroom is not therapeutic in this activity
- A nurse is admitting a client who has experienced a weight-loss of 11 kg/25 Lbs in 3 months.
The client weighs 40 kg(88lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority of care for this client?
a- identify the client's nutritional status b- request a mental health consult c-plan a therapeutic diet for the client
d- provide a structured environment for the client
Answer A- according to the nursing process the nurse should perform an assessment first to gather data regarding nutritional status and other findings in order to plan, implement, and evaluate care.
- mental health consult might be necessary but another aspect of care is priority
-it is important to provide structured environments for the client regarding meal times, for weighing, and monitoring eating- but other aspects of care is the priority
- A nurse at a college campus mental health counseling center is caring for a student who just
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failed an exam. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?a- conversion b- projection c- undoing
d- regression Answer B- the client is refusing to acknowledge unacceptable personal characteristics and transfers feelings, thought and traits onto another person.
-conversion as a defense mechanism in which the client unconsciously expresses emotional conflict via physical symptoms - such as paralysis or loss of sensory function
-undoing is a defense mechanism in which the client takes an action to make up for a wrong action or statement
-regression is a defense mechanism in which the client adopts a more primitive, immature behavior in response to an unwanted situation
- a nurse is caring for a client who was involved in a heavy combat and observed war
casualties. The nurse should suspect that the client is suffering PTSD if the client makes which of the following statements?a- "I check any room I enter because the enemy is still after me and could be hiding anywhere" b- " My child was born with a birth defect due to an exposure I had overseas" c- "I killed four enemy soldiers with my bare hands and saved my entire battalion."
d- "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Answer d- Many clients with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when exposed to events or objects reminiscent of the trauma.
- a nurse is caring for a group of clients on a mental health unit. Which of the following should
the nurse recognize as a maladaptive defense mechanism?a- a client slams a drawer after misplacing her wallet b- a man buys his partner a gift after flirting with his secretary c- a client forgets to schedule needed appointments when fearing chemotherapy
d- a client ignores the thought of pain when scheduled for oral surgery Answer c- repression occurs when a person deals with anxiety by unconsciously putting the unacceptable/ stressful thought out of their mind. This is considered maladaptive because it is interfering with healthy functioning aka not getting chemo
- a nurse is assessing a parent who lost a 12- year-old child in a car crash 2 years ago. Which
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