Basic Care and Comfort

The nurse visits a client at home. The client states, “I haven’t slept at all the last couple of nights.” Which therapeutic response would the nurse make?

A client with a diagnosis of 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 therapeutic response would the nurse make?

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply.

The nurse planning care for a military veteran needs to prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

The nurse is caring for a client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrants a need for follow-up?

The student nurse is preparing a presentation on circumstances in the health care environment that increase moral injury during the COVID-19 pandemic. Which scenario in the presentation would prompt the need for further teaching by the nurse educator?

A nurse expresses concerns to the charge nurse regarding unsafe working conditions related to the COVID-19 pandemic. The charge nurse acknowledges and utilizes which interventions to prevent further moral injury? Select all that apply.

Which assessments would the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply.

Which interventions would the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply.

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion?

A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action would the nurse take after noting this client’s behavior?

When planning care for a client with a history of violent behavior toward others, the nurse would include which interventions? Select all that apply.

What is the priority nursing action when admitting a client who has just attempted suicide?

The nurse is caring for an older client whose spouse died approximately 6 weeks ago. The client says, “There is no one left who cares about me. Everyone that I have loved is now gone.” Which nursing response allows for continued communication about the client’s state of mind?

The nurse would interpret which comment by a client diagnosed with battered spouse syndrome as being consistent with the presence of low self-esteem?

A client diagnosed with depression says to the nurse, “Things would be so much better for everyone if I just weren’t around.” Which response would the nurse make at this time to assess the client’s state of mind?

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide when which factor is identified?

The nurse would monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?

A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I don’t want help. I have other things to attend to that are more important.” The nurse attempts to discuss the client’s concerns, but the client dresses and begins to walk out of the hospital room. Which action would the nurse take at this time?

The nurse would monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?

Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation?

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client’s spouse states, “I don’t know why I don’t get out of this rotten situation.” Which response by the nurse addresses the spouse’s concerns?

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens would the nurse plan to continuously assess for?

The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action would be the priority?

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving?

A client is withdrawn, immobile and mute. Which appropriate action would the nurse take?

The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse would determine that which action is the priority of care at this time?

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the family anxiously tells the nurse, “My parent’s brain will be shocked with electricity. How can the doctor even think about doing this?” Which response by the nurse will best address the family’s concerns?

An understanding of borderline personality disorder would help the nurse determine that which problem is the priority for the client?

The client who is actively hallucinating is fearful that the voices will direct him to kill themself. Which therapeutic statement would the nurse make at this time?

The nurse caring for a client with a diagnosis of acute schizophrenia would use which approach when planning care?

An older client diagnosed with delirium becomes agitated and confused at night. Which nursing action would be the most important strategy to minimize the client’s risk for injury?

A client is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action would the nurse place priority on at this time?

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, “The leaders of a religious cult are being sent to assassinate me.” Which is the best response by the nurse?

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize which assessment finding as requiring immediate intervention?

A client with depression states to the nurse, “My life has been such a failure. Nothing I do turns out right.” Which response by the nurse will best address the client’s low sense of self-esteem?

The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention would the nurse include?

A client was raped a few weeks ago but still feels “as if it just happened to me.” Which response would the nurse make to the client?

Which statement indicates an understanding of the focus of milieu therapy?

The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which would the nurse include in the plan of care?

During a group session, a client threatens to “punch every one of you.” Which is the appropriate initial nursing action?

A client who has shared with the group at a previous session now suddenly gets up and announces, “I’m leaving.” How can the nurse initially meet the needs of both the client and the group?

A client’s phobia is being treated with systematic desensitization. Which modality is the focus of this therapy?

The nurse orienting a new client to a residential treatment center prepares to explain to the client that the emphasis of the center involves milieu therapy. Which is the focus of this type of therapy?

As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation would the nurse make about the client’s behavior?

When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention?

The nurse is developing a plan of care for a client who believes the unit’s food is being poisoned. Which strategy would the nurse plan to implement that will encourage the client to discuss feelings?

Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses’ station. The client becomes very loud and offensive, and demands to be seen by the psychiatrist immediately. Which intervention will address the needs of both the client and the milieu?

Which client behavior demonstrates denial of a sexual abuse event?