SAUNDERS NCLEX REVIEW QUESTIONS - UNIT 2 TEST WITH CORRECT VERIFIED ANSWERED QUESTIONS A C, Exams of Nursing

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CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

EXAM SOLUTION COVERS 2024/2025 BEST GRADED TO

SCORE A+ FOR PASS

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff?

1. Increase socialization of the client with peers.
2. Avoid laughing or whispering in front of the client.
3. Begin to educate the client about social supports in the community.
4. Have the client sign a release of information to appropriate parties for assessment purposes. - CORRECT ANSWERS ANS: 2 Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?
5. Chess
6. Writing
7. Ping pong
8. Basketball - CORRECT ANSWERS ANS: 2 Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

EXAM SOLUTION COVERS 2024/2025 BEST GRADED TO

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and should be avoided because they can stimulate aggression and increase psychomotor activity. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event?

1. Witnessing a murder
2. The death of a loved one
3. A fire that destroyed the client's home
4. A recent rape episode experienced by the client - CORRECT ANSWERS ANS: 2 Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
5. "You need to stop that behavior now."
6. "You will need to be placed in seclusion."
7. "You seem restless; tell me what is happening."
8. "You will need to be restrained if you do not change your behavior." - CORRECT ANSWERS ANS: 3 Rationale:

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

EXAM SOLUTION COVERS 2024/2025 BEST GRADED TO

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The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response?

1. "Have you talked to your family about this?"
2. "Everyone feels this way when they are depressed."
3. "You will feel better once your medication begins to work."
4. "You sound very upset. Are you thinking of hurting yourself?" - CORRECT ANSWERS ANS: 4 Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self- harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
5. The adolescent gives away a DVD and a cherished autographed picture of a performer.
6. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room.
7. The adolescent becomes angry while speaking on the telephone and slams down the receiver.
8. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking. - CORRECT ANSWERS ANS: 1 Rationale:

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent. A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication?

1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" - CORRECT ANSWERS ANS: 4 Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word "why" is nontherapeutic. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
5. Using open-ended questions and silence
6. Sharing personal preference regarding food choices

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition - CORRECT ANSWERS ANS: 1 Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing?
5. Denial
6. Projection 3.Regression
7. Rationalization - CORRECT ANSWERS ANS: 1 Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism?

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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1. Denial
2. Projection
3. Rationalization
4. Intellectualization - CORRECT ANSWERS ANS: 1 Rationale: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
5. Ask the client to leave the group for this session only.
6. Refer the client to another group that includes other manic clients.
7. Tell the client to stop monopolizing in a firm but compassionate manner.
8. Thank the client for the input, but inform the client that now others need a chance to contribute. - CORRECT ANSWERS ANS: 4 Rationale: If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed towards helping the client in a therapeutic manner.

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern?

1. "I don't believe this is true."
2. "The guards are not out to kill you."
3. "Do you feel afraid that people are trying to hurt you?"
4. "What makes you think the guards were sent to hurt you?" - CORRECT ANSWERS ANS: 3 Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
5. Encouraging quiet reading and writing for the first few days
6. Identification of physical activities that will provide exercise
7. No socializing activities, until the client asks to participate in milieu
8. A structured program of activities in which the client can participate - CORRECT ANSWERS ANS: 4 Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self- esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

EXAM SOLUTION COVERS 2024/2025 BEST GRADED TO

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When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?

1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continued contact with a crisis counselor
4. Eliminating all anxiety from daily situations - CORRECT ANSWERS ANS: 2 Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?
5. Setting limits on the client's behavior
6. Asking the client to leave the group session
7. Asking another nurse to escort the client out of the group session
8. Telling the client that they will not be able to attend any future group sessions - CORRECT ANSWERS ANS: 1 Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

EXAM SOLUTION COVERS 2024/2025 BEST GRADED TO

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A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?

1. Place the client in seclusion for 30 minutes.
2. Tell the client that the behavior is inappropriate.
3. Escort the client to their room, with the assistance of other staff.
4. Tell the client that their telephone privileges are revoked for 24 hours. - CORRECT ANSWERS ANS: 3 Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
5. Communicate expected behaviors to the client.
6. Ensure that the client knows that they are not in charge of the nursing unit.
7. Assist the client in identifying ways of setting limits on personal behaviors.
8. Follow through about the consequences of behavior in a nonpunitive manner.
9. Enforce rules by informing the client that they will not be allowed to attend therapy groups.
10. Have the client state the consequences for behaving in ways that are viewed as unacceptable. - CORRECT ANSWERS ANS: 1, 3, 4, 6

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care?

1. Provide safety for the client and other clients on the unit.
2. Provide the clients on the unit with a sense of comfort and safety.
3. Assist the staff in caring for the client in a controlled environment.
4. Offer the client a less stimulating area to calm down in and gain control - CORRECT ANSWERS ANS: 1 Rationale: Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?
5. Suggesting a reduction of medication
6. Allowing increased "in-room" activities
7. Increasing the level of suicide precautions

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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4. Allowing the client off-unit privileges as needed - CORRECT ANSWERS ANS: 3 Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?
5. Incessant talking and sexual innuendoes
6. Grandiose delusions and poor concentration
7. Outlandish behaviors and inappropriate dress
8. Nonstop physical activity and poor nutritional intake - CORRECT ANSWERS ANS: 4 Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. The correct option clearly presents a problem, however, that compromises physiological integrity and needs to be addressed immediately. The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
9. Engaging in immoral acts
10. Always reinforcing self-approval
11. Observing rigid rules and regulations
12. Having the need always to make the right decision - CORRECT ANSWERS ANS: 3

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety. A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan on responding to the client's statement?

1. Reassure the client that things will get better.
2. Tell the client that this is not true and that we all have a purpose in life.
3. Identify recent behaviors or accomplishments that demonstrate the client's skills.
4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings

• CORRECT ANSWERS ANS: 3 Rationale: Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement. A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely to last."
3. "Talking to oneself is a basic component of this form of therapy."

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4. "This form of therapy provides a negative reinforcement when the stimulus is produced." - CORRECT ANSWERS ANS: 4 Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy. The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client?
5. Anxiety
6. Unrealistic outlook
7. Lack of ability to cope effectively
8. Disturbances in thoughts and ideas - CORRECT ANSWERS ANS: 3 Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers and although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas. A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week, and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic?
9. "Why did you lose your job?"

CORRECT VERIFIED ANSWERED QUESTIONS A COMPLETE

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2. "There are homeless shelters available, and we will get you into one if you are evicted from your apartment." 3."If you get evicted from your apartment, we will commit you to the hospital, so you will have a place to eat and sleep."
3. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?" - CORRECT ANSWERS ANS: 4 Rationale: The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.