CoursePoint_ Lippincott NCLEX-RN PassPoint Powered by PrepU exam 2

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Question 1 See full question Following a sexual assault the client tells the nurse that she is on long-lasting birth control and has no intention of taking any legal action against her assailant.... The nurse advises the client that she stills needs follow-up care for early detection of which problem? Question 2 See full question The nurse is planning care for a client who has a history of making verbal threats and acting violently toward family members. The client is currently displaying intense anger towards the staff. What nursing diagnosis is most appropriate? Question 3 See full question A client with a diagnosis of antisocial personality disorder has a potential for violence and aggressive behavior. Which short-term client outcome is most appropriate for the nurse to include in the plan of care? f. Question 4 See full question The client is admitted to the hospital because of threatening, aggressive behavior toward the client’s family. Which factor is most important for the nurse to consider when assessing the angry client’s potential for violence? Question 5 See full question In working with a rape victim, which intervention is most important? Question 6 See full question As an angry client becomes more agitated while talking about problems, the nurse decides to ask for staff assistance in taking control of the situation when the client demonstrates which behavior? Question 7 See full question A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening others, angry outbursts, and two episodes of hitting a coworker at the client’s place of employment. The client is very anxious and tells the nurse, “I didn’t mean to hit him. He made me so mad that I just couldn’t help it. I hope I don’t hit anyone here.” To ensure a safe environment, what should the nurse do first? Question 8 See full question A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? Question 9 See full question Which nursing statement is most effective when the nurse is trying to defuse a client's impending violent behavior? Question 10 See full question Which nursing action is most appropriate when trying to defuse a client's impending violent behavior? Question 11 See full question An 16-year-old male is admitted to the facility after acting out his aggressions inappropriately at school. To better understand possible contributing factors, the nurse should assess for: Question 12 See full question Police bring a client to the emergency department after she threatens to kill her ex-husband. The client states emphatically, “The police should bring him in, not me. He is paranoid about my dating and has been stalking me for weeks. He is probably off his medicines. His case manager and the police will not do anything.” In what order should the following nursing actions be done from first to last? All options must be used. Question 13 See full question A client with acute stress disorder has avoided feelings of anger toward her rapist and cannot verbally express them. The nurse suggests which activity to assist the client with expressing her feelings? Question 14 See full question When caring for a client who was a victim of a crime, the nurse is aware that recovery from any crime can be a long and difficult process depending on the meaning it has for the client. What should the nurse establish as a victim’s ultimate goal in reconstructing his or her life? Question 15 See full question A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. “I don’t know why she didn’t keep the doors locked like I told her. I can’t believe she’s had sex with another man now.” How should the nurse respond? Question 16 See full question A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether the client wants to file a report, the nurse's next priority is to offer which intervention to the client? Question 17 See full question Based on a client's history of violence toward others and inability to cope with anger, what should the nurse use as the most important indicator of goal achievement before discharge? Question 18 See full question The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client? Question 19 See full question A 75-year-old woman was brought to the crisis center by her husband. The husband reports that his wife has been in shock and anxious since her purse was stolen outside of their home. The woman blames herself for being robbed, is worried about her stolen wallet and credit cards, and is afraid to go home. What nursing actions are indicated? Select all that apply. Question 20 See full question A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, “You’re going to tell me who did this to you. What’s his name?” Which is the nurse’s best response? Question 21 See full question An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? Question 22 See full question A client with antisocial personality disorder tells the nurse, “I punched the guy out because he deserved it, and then the cops arrested me.” Which response would be most helpful to the client? Question 23 See full question A client’s face is flushed. The client is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle? Question 24 See full question A client is admitted after the police found the client sleeping in a car for three nights. The client says, “My spouse kicked me out and is divorcing me. It wasn’t my fault I was fired from work. My spouse and boss are plotting against me because I’m smarter than they are.” The client then pounds the table and says, “I’m not staying here, and you can’t stop me.” What should be included in the client’s immediate plan of care? Select all that apply. Question 25 See full question 21s The nurse assesses a client who is pacing, using profanity, and is argumentative. What is the most appropriate statement for the nurse to make? Question 26 See full question 40s The school nurse is counseling a female client who is concerned about an incident that occurred at a school dance. The young client describes becoming drowsy and disoriented after drinking punch and waking up hours later in the back of a stranger’s car. What is the most appropriate advice for the nurse to give the adolescent? Correct response: “It’s possible that you were raped and will need information on pregnancy testing.” Question 27 See full question Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? Question 28 See full question A nurse is admitting a client in the crisis center who has been raped. Which of the following is the priority nursing intervention? Question 29 See full question In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement? Question 30 See full question The nurse judges a client to no longer need constant one-to-one observation for self-directed violence when the client exhibits which behavior? Question 31 See full question 1m 6s A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts, and two episodes of hitting a coworker at the grocery store where he works. The client is very anxious and tells the nurse who admits him, “I did not mean to hit him. He made me so mad that I just could not help it. I hope I do not hit anyone here.” The nurse should respond: Question 32 See full question 51s A client loses control and throws two chairs toward another client. What should the nurse do next? Question 33 See full question 1m 50s A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply. Question 34 See full question 39s During the admission interview, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years earlier. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me." The nurse's most supportive response would be: Question 35 See full question 54s The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate? Question 36 See full question 22s When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions? Question 37 See full question 54s A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client's anger? Question 38 See full question 47s A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent? Question 39 See full question 1m 23s A nurse is working in the emergency room when a police officer walks in with a rape victim to be examined. If the nursing goal is to reduce client anxiety, which interventions would be appropriate? Select all that apply. Question 40 See full question 2m 18s A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, “They said I was gay because I had sex with an older neighbor when I was 8 years old. I’m not gay!” Which nursing intervention would be appropriate? Select all that apply. [Show More]

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