HESI Computerized Adaptive Testing Test Bank With Answers (424 Solved Questions)
HESI Computerized Adaptive Testing Test Bank With Answers allows you to practice consistently with real exam papers.
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HESI Computerized Adaptive Testing
(CAT) Test Bank With Rationales.
HESI Computerized Adaptive
Testing (CAT) Test Bank
Question 1
A nurse is counseling the spouse of a client who has a history of alcohol abuse.
What does the nurse explain is the main reason for drinking alcohol in people
with a long history of alcohol abuse?
A. They are dependent on it.
B. They lack the motivation to stop.
C. They use it for coping.
D. They enjoy the associated socialization. ✓ Ans- a
Alcohol causes both physical and psychological dependence; the individual
needs the alcohol to function. Alcoholism is a disorder that entails physical and
psychological dependence. Because alcohol is so physiologically addictive, the
client's body craves the alcohol, so most clients lack the motivation to stop
because they will go into withdrawal. Clients who abuse alcohol have numbed
their ability to utilize other coping mechanisms, so alcohol is used as an excuse
for coping. People with alcoholism usually drink alone or feel alone in a crowd;
socialization is not the prime reason for their drinking.
Question 2
How do adolescents establish family identity during psychosocial development?
Select all that apply.
A. By acting independently to make his or her own decisions
B. By evaluating his or her own health with a feeling
of well-being
C. By fostering his or her own development within a
balanced family structure
D. By building close peer relationships to achieve
acceptance in the society
E. By achieving marked physical changes ✓ Ans-
ac
HESI Computerized Adaptive Testing
(CAT) Test Bank With Rationales.
HESI Computerized Adaptive
Testing (CAT) Test Bank
Question 1
A nurse is counseling the spouse of a client who has a history of alcohol abuse.
What does the nurse explain is the main reason for drinking alcohol in people
with a long history of alcohol abuse?
A. They are dependent on it.
B. They lack the motivation to stop.
C. They use it for coping.
D. They enjoy the associated socialization. ✓ Ans- a
Alcohol causes both physical and psychological dependence; the individual
needs the alcohol to function. Alcoholism is a disorder that entails physical and
psychological dependence. Because alcohol is so physiologically addictive, the
client's body craves the alcohol, so most clients lack the motivation to stop
because they will go into withdrawal. Clients who abuse alcohol have numbed
their ability to utilize other coping mechanisms, so alcohol is used as an excuse
for coping. People with alcoholism usually drink alone or feel alone in a crowd;
socialization is not the prime reason for their drinking.
Question 2
How do adolescents establish family identity during psychosocial development?
Select all that apply.
A. By acting independently to make his or her own decisions
B. By evaluating his or her own health with a feeling
of well-being
C. By fostering his or her own development within a
balanced family structure
D. By building close peer relationships to achieve
acceptance in the society
E. By achieving marked physical changes ✓ Ans-
ac
Page of1 172
HESI Computerized Adaptive Testing
(CAT) Test Bank With Rationales.
HESI Computerized Adaptive
Testing (CAT) Test Bank
Question 1
A nurse is counseling the spouse of a client who has a history of alcohol abuse.
What does the nurse explain is the main reason for drinking alcohol in people
with a long history of alcohol abuse?
A. They are dependent on it.
B. They lack the motivation to stop.
C. They use it for coping.
D. They enjoy the associated socialization. ✓ Ans- a
Alcohol causes both physical and psychological dependence; the individual
needs the alcohol to function. Alcoholism is a disorder that entails physical and
psychological dependence. Because alcohol is so physiologically addictive, the
client's body craves the alcohol, so most clients lack the motivation to stop
because they will go into withdrawal. Clients who abuse alcohol have numbed
their ability to utilize other coping mechanisms, so alcohol is used as an excuse
for coping. People with alcoholism usually drink alone or feel alone in a crowd;
socialization is not the prime reason for their drinking.
Question 2
How do adolescents establish family identity during psychosocial development?
Select all that apply.
A. By acting independently to make his or her own decisions
B. By evaluating his or her own health with a feeling
of well-being
C. By fostering his or her own development within a
balanced family structure
D. By building close peer relationships to achieve
acceptance in the society
E. By achieving marked physical changes ✓ Ans-
ac
HESI Computerized Adaptive Testing
(CAT) Test Bank With Rationales.
HESI Computerized Adaptive
Testing (CAT) Test Bank
Question 1
A nurse is counseling the spouse of a client who has a history of alcohol abuse.
What does the nurse explain is the main reason for drinking alcohol in people
with a long history of alcohol abuse?
A. They are dependent on it.
B. They lack the motivation to stop.
C. They use it for coping.
D. They enjoy the associated socialization. ✓ Ans- a
Alcohol causes both physical and psychological dependence; the individual
needs the alcohol to function. Alcoholism is a disorder that entails physical and
psychological dependence. Because alcohol is so physiologically addictive, the
client's body craves the alcohol, so most clients lack the motivation to stop
because they will go into withdrawal. Clients who abuse alcohol have numbed
their ability to utilize other coping mechanisms, so alcohol is used as an excuse
for coping. People with alcoholism usually drink alone or feel alone in a crowd;
socialization is not the prime reason for their drinking.
Question 2
How do adolescents establish family identity during psychosocial development?
Select all that apply.
A. By acting independently to make his or her own decisions
B. By evaluating his or her own health with a feeling
of well-being
C. By fostering his or her own development within a
balanced family structure
D. By building close peer relationships to achieve
acceptance in the society
E. By achieving marked physical changes ✓ Ans-
ac
Page of2 172
An adolescent establishes family identity by acting independently for taking
important decisions about self. They also need to foster their development
along with maintaining a balanced family structure. Health identity is associated
with the evaluation of one's own health with a feeling of well-being. By building
close peer relationships, an adolescent develops a sense of belonging,
approval, and the opportunity to learn acceptable behavior. These actions
establish an adolescent's group identity. The sound and healthy growth of the
adolescent, with marked physical changes, helps to build an adolescent's
sexual identity.
Question 3
A clinic nurse observes a b-year-old client sitting alone, rocking and staring at
a small, shiny top that she is spinning. Later the father relates his concerns,
stating, "She pushes me away. She doesn't speak, and she only shows feelings
when I take her top away. Is it something I've done?" What is the most
therapeutic initial response by the nurse?
A. Asking the father about his relationship with his wife
B. Asking the father how he held the child when she was an infant
C. Telling the father that it is nothing he has done and sharing the nurse's
observations of the child
D. Telling the father not to be concerned and stressing that the child will outgrow
this developmental phase ✓ Ans- c
The nurse provides support in a nonjudgmental way by sharing information and
observations about the child. This child exhibits symptoms of autism, which is
not attributable to the actions of the parents. Asking the father about his
relationship with his wife or how he held the child when she was an infant
indirectly indicates that the parent may be at fault; it negates the father's need
for support and increases his sense of guilt.
Telling the father not to be concerned and stressing that the child will
outgrow this developmental phase is false reassurance that does not
provide support; the father recognizes that something is wrong.
Question 4
What is most appropriate for a nurse to say when interviewing a newly admitted
depressed client whose thoughts are focused on feelings of worthlessness and
failure?
A. ”Tell me how you feel about yourself."
B. "Tell me what has been bothering you."
C. "Why do you feel so bad about yourself?"
An adolescent establishes family identity by acting independently for taking
important decisions about self. They also need to foster their development
along with maintaining a balanced family structure. Health identity is associated
with the evaluation of one's own health with a feeling of well-being. By building
close peer relationships, an adolescent develops a sense of belonging,
approval, and the opportunity to learn acceptable behavior. These actions
establish an adolescent's group identity. The sound and healthy growth of the
adolescent, with marked physical changes, helps to build an adolescent's
sexual identity.
Question 3
A clinic nurse observes a b-year-old client sitting alone, rocking and staring at
a small, shiny top that she is spinning. Later the father relates his concerns,
stating, "She pushes me away. She doesn't speak, and she only shows feelings
when I take her top away. Is it something I've done?" What is the most
therapeutic initial response by the nurse?
A. Asking the father about his relationship with his wife
B. Asking the father how he held the child when she was an infant
C. Telling the father that it is nothing he has done and sharing the nurse's
observations of the child
D. Telling the father not to be concerned and stressing that the child will outgrow
this developmental phase ✓ Ans- c
The nurse provides support in a nonjudgmental way by sharing information and
observations about the child. This child exhibits symptoms of autism, which is
not attributable to the actions of the parents. Asking the father about his
relationship with his wife or how he held the child when she was an infant
indirectly indicates that the parent may be at fault; it negates the father's need
for support and increases his sense of guilt.
Telling the father not to be concerned and stressing that the child will
outgrow this developmental phase is false reassurance that does not
provide support; the father recognizes that something is wrong.
Question 4
What is most appropriate for a nurse to say when interviewing a newly admitted
depressed client whose thoughts are focused on feelings of worthlessness and
failure?
A. ”Tell me how you feel about yourself."
B. "Tell me what has been bothering you."
C. "Why do you feel so bad about yourself?"
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D. "What can we do to help you while you're here?" ✓ Ans- a
Because major depression is a result of the client's feelings of self-rejection, it
is important for the nurse to have the client initially identify these feelings
before developing a plan of care. Later discussion should be focused on other
topics to prevent reinforcement of negative thoughts and feelings. "Tell me
what has been bothering you" is asking the client to draw a conclusion; the
client may be unable to do so at this time. Also, depression may be related not
to external events but instead to a client's psychobiology. Asking why does not
let a client explore feelings; it usually elicits an "I don't know" response. "What
can we do to help you while you're here?" is beyond the scope of the client's
abilities at this time.
Question 5
A client is admitted to the mental health unit with the diagnosis of major
depressive disorder. Which statement alerts the nurse to the possibility of a
suicide attempt?
A. ”I don't feel too good today."
B. "I feel much better; today is a lovely day."
C. "I feel a little better, but it probably won't last." d
D. "I'm really tired today, so I'll take things a little slower." ✓ Ans- b
A rapid mood upswing and psychomotor change may signal that the client has
made a decision and has developed a plan for suicide. "I don't feel too good
today"; "I feel a little better, but it probably won't last"; and "I'm really tired
today, so I'll take things a little slower" are all typical of the depressed client;
none of these statements signals a change in mood.
Question 6
During a group discussion it is learned that a group member hid suicidal urges
and committed suicide several days ago. What should the nurse leading the
group be prepared to manage?
A. Guilt of the co-leaders for failing to anticipate and prevent the suicide
B. Guilt of group members because they could not prevent another's suicide
C. Lack of concern over the suicide expressed by several of the members in the group
D. Fear by some members that their own suicidal urges may go unnoticed and that they
may go unprotected ✓ Ans- d
Ambivalence about life and death, plus the introspection commonly found in
clients with emotional problems, can lead to increased anxiety and fear among
the group members. These feelings must be handled within the support and
supervisory systems for the staff; the group members are the primary concern.
Guilt that the group's leaders or members might feel because they could not
D. "What can we do to help you while you're here?" ✓ Ans- a
Because major depression is a result of the client's feelings of self-rejection, it
is important for the nurse to have the client initially identify these feelings
before developing a plan of care. Later discussion should be focused on other
topics to prevent reinforcement of negative thoughts and feelings. "Tell me
what has been bothering you" is asking the client to draw a conclusion; the
client may be unable to do so at this time. Also, depression may be related not
to external events but instead to a client's psychobiology. Asking why does not
let a client explore feelings; it usually elicits an "I don't know" response. "What
can we do to help you while you're here?" is beyond the scope of the client's
abilities at this time.
Question 5
A client is admitted to the mental health unit with the diagnosis of major
depressive disorder. Which statement alerts the nurse to the possibility of a
suicide attempt?
A. ”I don't feel too good today."
B. "I feel much better; today is a lovely day."
C. "I feel a little better, but it probably won't last." d
D. "I'm really tired today, so I'll take things a little slower." ✓ Ans- b
A rapid mood upswing and psychomotor change may signal that the client has
made a decision and has developed a plan for suicide. "I don't feel too good
today"; "I feel a little better, but it probably won't last"; and "I'm really tired
today, so I'll take things a little slower" are all typical of the depressed client;
none of these statements signals a change in mood.
Question 6
During a group discussion it is learned that a group member hid suicidal urges
and committed suicide several days ago. What should the nurse leading the
group be prepared to manage?
A. Guilt of the co-leaders for failing to anticipate and prevent the suicide
B. Guilt of group members because they could not prevent another's suicide
C. Lack of concern over the suicide expressed by several of the members in the group
D. Fear by some members that their own suicidal urges may go unnoticed and that they
may go unprotected ✓ Ans- d
Ambivalence about life and death, plus the introspection commonly found in
clients with emotional problems, can lead to increased anxiety and fear among
the group members. These feelings must be handled within the support and
supervisory systems for the staff; the group members are the primary concern.
Guilt that the group's leaders or members might feel because they could not
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prevent another's suicide will probably be a secondary concern of the group
leader. Lack of concern over the suicide expressed by several of the members in
the group is not a primary concern, but this should be explored later to
determine the reason for such apparent indifference, which may be a mask to
cover true feelings.
Question 7
Which screening report will help the nurse determine skeletal growth
in a child?
A. Electroencephalogram reports
B. .Radiographs of the hand and wrist
C. .Magnetic resonance imaging (MRI)
D. .Denver Developmental Screening Test ✓ Ans- b
Skeletal growth in a child can be determined from the ossification centers. At e
to f months of age, the capitate and hamate bones in the wrist are the earliest
centers. Therefore radiographs of the hand and wrist will help determine
skeletal growth in the child.
Electroencephalogram reports will help assess a child's brain activity. MRI is
used to scan the internal structures of a client. The Denver Developmental
Screening Test is used to understand developmental issues of a child.
Question 8
A client describes his delusions in minute detail to the nurse. How should the
nurse respond?
A. Changing the topic to reality-based events
B. Continuing to discuss the delusion with the client
C. Getting the client involved in a social project with peers
D. Disputing the perceptions with the use of logical thinking ✓ Ans- a
Decreasing time spent on delusions prevents reinforcement of psychotic
thinking. Discussing reality-based events improves contact with reality.
Encouraging discussion will give validity to the delusion. The client will have
difficulty getting involved in a social activity; the activity will not stop the
delusion. Challenging the client may increase anxiety.
Question 9
A nurse working on a mental health unit is caring for several clients who are at
risk for suicide. Which client is at the greatest risk for successful suicide?
prevent another's suicide will probably be a secondary concern of the group
leader. Lack of concern over the suicide expressed by several of the members in
the group is not a primary concern, but this should be explored later to
determine the reason for such apparent indifference, which may be a mask to
cover true feelings.
Question 7
Which screening report will help the nurse determine skeletal growth
in a child?
A. Electroencephalogram reports
B. .Radiographs of the hand and wrist
C. .Magnetic resonance imaging (MRI)
D. .Denver Developmental Screening Test ✓ Ans- b
Skeletal growth in a child can be determined from the ossification centers. At e
to f months of age, the capitate and hamate bones in the wrist are the earliest
centers. Therefore radiographs of the hand and wrist will help determine
skeletal growth in the child.
Electroencephalogram reports will help assess a child's brain activity. MRI is
used to scan the internal structures of a client. The Denver Developmental
Screening Test is used to understand developmental issues of a child.
Question 8
A client describes his delusions in minute detail to the nurse. How should the
nurse respond?
A. Changing the topic to reality-based events
B. Continuing to discuss the delusion with the client
C. Getting the client involved in a social project with peers
D. Disputing the perceptions with the use of logical thinking ✓ Ans- a
Decreasing time spent on delusions prevents reinforcement of psychotic
thinking. Discussing reality-based events improves contact with reality.
Encouraging discussion will give validity to the delusion. The client will have
difficulty getting involved in a social activity; the activity will not stop the
delusion. Challenging the client may increase anxiety.
Question 9
A nurse working on a mental health unit is caring for several clients who are at
risk for suicide. Which client is at the greatest risk for successful suicide?
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E. Young adult who is acutely psychotic
F. Adolescent who was recently sexually abused
G. Older single man just found to have pancreatic cancer
H. Middle-age woman experiencing dysfunctional grieving ✓ Ans- c
Older single men with chronic health problems are at the highest risk of
suicide. This is because men have fewer social supports than women do. (Men
are less social then women in general.) Less social support at times of stress can
increase the risk of suicide. Also, chronic health problems can lead to learned
helplessness, which can lead to depression.
People who are acutely psychotic as a group are at higher risk for suicide, but
they do not have the suicide rate of older single adult men with chronic health
problems. An adolescent who was recently sexually abused, although severely
traumatized, does not have the risk of suicide of an older single man with
chronic health problems. Dysfunctional grieving is prolonged grieving that is
characterized by greater disability and dysfunctional patterns of behavior.
Although people with complicated dysfunctional grieving may be at risk for
self- directed violence, they do not have the suicide risk of older single men
with chronic health problems.
Question 10
Which stages would the nurse explain that a toddler goes through, according to
Freud's theory? Select all that apply.
A. Oral
B. Anal
C. Phallic
D. Genital
E. Latency ✓ Ans- ab
According to Freud's theory, a toddler goes through the oral and anal stages.
The phallic stage is seen in children between the ages of c to f years. The
genital stage is seen during puberty through adulthood. The latency stage is
seen in children ages f to ab years of age.
Question 12
A client is found to have a borderline personality disorder. What behavior does
the nurse consider is most typical of these clients?
A. Inept
B. Eccentric
C. Impulsive
D. Dependent ✓ Ans- c
E. Young adult who is acutely psychotic
F. Adolescent who was recently sexually abused
G. Older single man just found to have pancreatic cancer
H. Middle-age woman experiencing dysfunctional grieving ✓ Ans- c
Older single men with chronic health problems are at the highest risk of
suicide. This is because men have fewer social supports than women do. (Men
are less social then women in general.) Less social support at times of stress can
increase the risk of suicide. Also, chronic health problems can lead to learned
helplessness, which can lead to depression.
People who are acutely psychotic as a group are at higher risk for suicide, but
they do not have the suicide rate of older single adult men with chronic health
problems. An adolescent who was recently sexually abused, although severely
traumatized, does not have the risk of suicide of an older single man with
chronic health problems. Dysfunctional grieving is prolonged grieving that is
characterized by greater disability and dysfunctional patterns of behavior.
Although people with complicated dysfunctional grieving may be at risk for
self- directed violence, they do not have the suicide risk of older single men
with chronic health problems.
Question 10
Which stages would the nurse explain that a toddler goes through, according to
Freud's theory? Select all that apply.
A. Oral
B. Anal
C. Phallic
D. Genital
E. Latency ✓ Ans- ab
According to Freud's theory, a toddler goes through the oral and anal stages.
The phallic stage is seen in children between the ages of c to f years. The
genital stage is seen during puberty through adulthood. The latency stage is
seen in children ages f to ab years of age.
Question 12
A client is found to have a borderline personality disorder. What behavior does
the nurse consider is most typical of these clients?
A. Inept
B. Eccentric
C. Impulsive
D. Dependent ✓ Ans- c
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Impulsive, potentially self-damaging behaviors are typical of clients with this
personality disorder. Inept behavior, by itself, is not typical of clients with any
specific personality disorder. Eccentric behavior is more typical of the client
with a schizotypal personality disorder. Dependent behavior is more typical of
the client with a dependent personality disorder.
Question 13
An older adult, accompanied by family members, is admitted to a long-term
care facility with symptoms of dementia. What initial statement by the nurse
during the admission procedure would be most helpful to this client?
A. ”You're a little disoriented now, but don't worry. You'll be all right in a few days."
B. "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you."
C. "I'm the nurse on duty today. You're in the hospital. Your family can stay with you for a
while."
D. ”Let me introduce you to the staff here first. In a little while I'll get you
acquainted with our unit routine." ✓ Ans- b
Familiarity with the environment and a self-introduction may help promote
security and feelings of trust. Telling the client "You're a little disoriented now,
but don't worry. You'll be all right in a few days" denies the client's feelings
and provides false reassurance. A self- introducing one's self followed by telling
the client that of being in the hospital and that the family may stay for a while
denies the client's feelings but does provide self-introduction and orientation
regarding the client's location. A person under stress cannot assimilate much
information; verbiage could lead to more confusion.
Question 14
Which identity may fail to develop if the adolescent fails to feel a sense of
belonging and acceptance?
A. Sexual identity
B. Group identity
C. Family identity
D. Health identity ✓ Ans- b
Failure to feel acceptance and belonging results in failure to establish a group
identity. A lack of physical evidence of maturity can predispose the adolescent
to fail to establish a sexual identity. Adolescents depend on these physical cues
because they want assurance of maleness or femaleness and do not wish to be
different from their peers. If an adolescent fails to foster independence and
balance in the family structure, it may hamper family identity. Healthy
adolescents evaluate their own health on the basis of feelings of well- being,
ability to function normally, and absence of symptoms.
Impulsive, potentially self-damaging behaviors are typical of clients with this
personality disorder. Inept behavior, by itself, is not typical of clients with any
specific personality disorder. Eccentric behavior is more typical of the client
with a schizotypal personality disorder. Dependent behavior is more typical of
the client with a dependent personality disorder.
Question 13
An older adult, accompanied by family members, is admitted to a long-term
care facility with symptoms of dementia. What initial statement by the nurse
during the admission procedure would be most helpful to this client?
A. ”You're a little disoriented now, but don't worry. You'll be all right in a few days."
B. "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you."
C. "I'm the nurse on duty today. You're in the hospital. Your family can stay with you for a
while."
D. ”Let me introduce you to the staff here first. In a little while I'll get you
acquainted with our unit routine." ✓ Ans- b
Familiarity with the environment and a self-introduction may help promote
security and feelings of trust. Telling the client "You're a little disoriented now,
but don't worry. You'll be all right in a few days" denies the client's feelings
and provides false reassurance. A self- introducing one's self followed by telling
the client that of being in the hospital and that the family may stay for a while
denies the client's feelings but does provide self-introduction and orientation
regarding the client's location. A person under stress cannot assimilate much
information; verbiage could lead to more confusion.
Question 14
Which identity may fail to develop if the adolescent fails to feel a sense of
belonging and acceptance?
A. Sexual identity
B. Group identity
C. Family identity
D. Health identity ✓ Ans- b
Failure to feel acceptance and belonging results in failure to establish a group
identity. A lack of physical evidence of maturity can predispose the adolescent
to fail to establish a sexual identity. Adolescents depend on these physical cues
because they want assurance of maleness or femaleness and do not wish to be
different from their peers. If an adolescent fails to foster independence and
balance in the family structure, it may hamper family identity. Healthy
adolescents evaluate their own health on the basis of feelings of well- being,
ability to function normally, and absence of symptoms.
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Question 15
In her eighth month of pregnancy, a bd-year-old client is brought to the
hospital by the police, who were called when she barricaded herself in a ladies'
restroom of a restaurant. During admission the client shouts, "Don't come near
me! My stomach is filled with bombs, and I'll blow up this place if anyone
comes near me." What does the nurse conclude that the client is exhibiting?
A. Ideas of reference
B. Loose associations
C. Delusional thinking
D. Tactile hallucinations ✓ Ans- c
Delusions are false fixed beliefs that have a minimal basis in reality. This is a
somatic delusion. Ideas of reference are false beliefs that every statement or
action of others relates to the individual. Loose associations are verbalizations
that sound disjointed to the listener. Tactile hallucinations are false sensory
perceptions of touch without external stimuli.
Question 16
Which should the nurse encourage for a school-age client diagnosed with a
chronic illness to enhance a sense of accomplishment?
A. Wearing make-up
B. Making up missed work
C. Participating in sports activities
D. Participating in creative activities ✓ Ans- b
Making up missed work is an activity the nurse can encourage to enhance a
sense of accomplishment for a school-age client who is diagnosed with a
chronic illness. Wearing make-up is often encouraged for an adolescent
client. Participation in sports activities enhances the development of peer
relationship in the school-age child. Participating in creative activities allows
the school-age child to learn through concrete operations.
Question 17
A nurse is caring for a client exhibiting compulsive behaviors. The nurse
concludes that the compulsive behavior usually incorporates the use of which
defense mechanism?
A. Projection
B. Regression
C. Displacement
D. Rationalization ✓ Ans- c
Displacement is the unconscious redirection of an emotion from a threatening
Question 15
In her eighth month of pregnancy, a bd-year-old client is brought to the
hospital by the police, who were called when she barricaded herself in a ladies'
restroom of a restaurant. During admission the client shouts, "Don't come near
me! My stomach is filled with bombs, and I'll blow up this place if anyone
comes near me." What does the nurse conclude that the client is exhibiting?
A. Ideas of reference
B. Loose associations
C. Delusional thinking
D. Tactile hallucinations ✓ Ans- c
Delusions are false fixed beliefs that have a minimal basis in reality. This is a
somatic delusion. Ideas of reference are false beliefs that every statement or
action of others relates to the individual. Loose associations are verbalizations
that sound disjointed to the listener. Tactile hallucinations are false sensory
perceptions of touch without external stimuli.
Question 16
Which should the nurse encourage for a school-age client diagnosed with a
chronic illness to enhance a sense of accomplishment?
A. Wearing make-up
B. Making up missed work
C. Participating in sports activities
D. Participating in creative activities ✓ Ans- b
Making up missed work is an activity the nurse can encourage to enhance a
sense of accomplishment for a school-age client who is diagnosed with a
chronic illness. Wearing make-up is often encouraged for an adolescent
client. Participation in sports activities enhances the development of peer
relationship in the school-age child. Participating in creative activities allows
the school-age child to learn through concrete operations.
Question 17
A nurse is caring for a client exhibiting compulsive behaviors. The nurse
concludes that the compulsive behavior usually incorporates the use of which
defense mechanism?
A. Projection
B. Regression
C. Displacement
D. Rationalization ✓ Ans- c
Displacement is the unconscious redirection of an emotion from a threatening
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source to a nonthreatening source. Projection is the attribution of one's
unacceptable feelings and thoughts to someone else. Regression is the return
to an earlier, more comfortable level of behavior; it is a retreat from the present.
Rationalization is the attempt to make unacceptable behavior or feelings
acceptable by justifying the reasons for them.
Question 18
A client is admitted for a biopsy of a tumor in her left breast. The client
states, "I know it can't be cancer, because it doesn't hurt." What is the
nurse's most therapeutic response?
A. ”Let’s hope that it isn't malignant."
B. ”What do you know about breast cancer?"
C. "Most lumps in the breast are not malignant.”
D. "Has your primary healthcare provider told you that it wasn't cancer?" ✓ Ans-
b
Asking what the client knows about breast cancer allows the nurse to assess
the client's understanding of breast cancer and to clarify any misconceptions.
Saying that they should hope that the growth isn't malignant avoids an
opportunity to teach, and it is a type of false reassurance. The statement may
actually increase feelings of hopelessness if the lesion is determined to be
malignant. Although correct, stating that most lesions are benign provides a
false sense of security and avoids an opportunity to teach. Asking whether the
primary healthcare provider has told the client that it wasn't cancer focuses on
what the primary healthcare provider said rather than on what the client knows
and may limit further communication of feelings and beliefs.
Question 19
A nurse in the emergency department is assessing a client who has been
physically and sexually assaulted. What is the nurse's priority during
assessment?
A. The family's feelings about the attack
B. The client's feelings of social isolation
C. The client's ability to cope with the situation
D. Disturbance in the client's thought processes ✓ Ans- c
The situation is so traumatic that the individual may be unable to use past
coping behaviors to comprehend what has occurred. Assessing emotions that
occur in response to news of the attack will occur later. The client should be the
focus of care at this time. Social isolation is not an immediate concern. Coping
source to a nonthreatening source. Projection is the attribution of one's
unacceptable feelings and thoughts to someone else. Regression is the return
to an earlier, more comfortable level of behavior; it is a retreat from the present.
Rationalization is the attempt to make unacceptable behavior or feelings
acceptable by justifying the reasons for them.
Question 18
A client is admitted for a biopsy of a tumor in her left breast. The client
states, "I know it can't be cancer, because it doesn't hurt." What is the
nurse's most therapeutic response?
A. ”Let’s hope that it isn't malignant."
B. ”What do you know about breast cancer?"
C. "Most lumps in the breast are not malignant.”
D. "Has your primary healthcare provider told you that it wasn't cancer?" ✓ Ans-
b
Asking what the client knows about breast cancer allows the nurse to assess
the client's understanding of breast cancer and to clarify any misconceptions.
Saying that they should hope that the growth isn't malignant avoids an
opportunity to teach, and it is a type of false reassurance. The statement may
actually increase feelings of hopelessness if the lesion is determined to be
malignant. Although correct, stating that most lesions are benign provides a
false sense of security and avoids an opportunity to teach. Asking whether the
primary healthcare provider has told the client that it wasn't cancer focuses on
what the primary healthcare provider said rather than on what the client knows
and may limit further communication of feelings and beliefs.
Question 19
A nurse in the emergency department is assessing a client who has been
physically and sexually assaulted. What is the nurse's priority during
assessment?
A. The family's feelings about the attack
B. The client's feelings of social isolation
C. The client's ability to cope with the situation
D. Disturbance in the client's thought processes ✓ Ans- c
The situation is so traumatic that the individual may be unable to use past
coping behaviors to comprehend what has occurred. Assessing emotions that
occur in response to news of the attack will occur later. The client should be the
focus of care at this time. Social isolation is not an immediate concern. Coping
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skills, not thought processes, are challenged at this time.
Question 20
A client is admitted to the psychiatric unit with the diagnosis of obsessive-
compulsive disorder. The client washes her hands more than b0 times a day,
and they are raw and bloody. What defense mechanism does the nurse
conclude that the client is using to ease anxiety?
A. Undoing
B. Projection
C. Introjection
D. Displacement ✓ Ans- a
Undoing is an act that partially negates a previous one; the client is using this
defense mechanism to atone for unacceptable acts or wishes. The client is not
attributing self- thoughts or impulses to another person or group, which is
called projection. The client is not absorbing into the self a hated or loved
object (introjection). Displacement is the transferring of feelings from one
person, object, or experience onto another, less threatening person, object, or
experience.
skills, not thought processes, are challenged at this time.
Question 20
A client is admitted to the psychiatric unit with the diagnosis of obsessive-
compulsive disorder. The client washes her hands more than b0 times a day,
and they are raw and bloody. What defense mechanism does the nurse
conclude that the client is using to ease anxiety?
A. Undoing
B. Projection
C. Introjection
D. Displacement ✓ Ans- a
Undoing is an act that partially negates a previous one; the client is using this
defense mechanism to atone for unacceptable acts or wishes. The client is not
attributing self- thoughts or impulses to another person or group, which is
called projection. The client is not absorbing into the self a hated or loved
object (introjection). Displacement is the transferring of feelings from one
person, object, or experience onto another, less threatening person, object, or
experience.
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Question 21
The parents tell the nurse that their preschooler often awakes from sleep
screaming in the middle of the night. The preschooler is not easily comforted
and screams if the parents try to restrain the child. What does the nurse
instruct the parents?
A. ”Always read a story to the child before bedtime."
B. "Intervene only if necessary to protect the child from injury."
C. "Discuss counseling options with the primary health care provider."
D. "Try to wake the child and ask the child to describe the dream." ✓ Ans- b
Waking up screaming from sleep at night indicates sleep terrors. The nurse
should advise the parents to observe the child and intervene only if there is a
risk for injury. Reading a story before bedtime helps to calm the child before
sleeping, but it does not ensure that the child will not have a sleep terror. There
is no need for professional counseling, because sleep terrors are a common
phenomenon in preschool-age children. The child is not aware of anybody's
presence during a sleep terror, so it is not appropriate to wake up the child; this
may cause the child to scream and thrash more.
Question 22
A client who was forced into early retirement is found to have severe
depression. The client says, "I feel useless, and I've got nothing to do." What is
the best initial response by the nurse?
A. ”Tell me more about feeling useless."
B. "Volunteering can help you fill your time."
C. "Your illness is adding to your current feelings."
D. "Let's talk about what you'd like to be doing right now." ✓ Ans- a
An open-ended response encourages further discussion and allows
exploration of feelings. Telling the client that volunteering will help pass the
time ignores the client's feelings. The depression is not adding to the feelings;
the feelings are causing the depression. Asking the client to talk about what
the client would rather be doing ignores the client's feelings.
Question 23
What characteristic is most essential for the nurse caring for a client undergoing
mental health care?
A. Empathy
B. Sympathy
C. Organization
Question 21
The parents tell the nurse that their preschooler often awakes from sleep
screaming in the middle of the night. The preschooler is not easily comforted
and screams if the parents try to restrain the child. What does the nurse
instruct the parents?
A. ”Always read a story to the child before bedtime."
B. "Intervene only if necessary to protect the child from injury."
C. "Discuss counseling options with the primary health care provider."
D. "Try to wake the child and ask the child to describe the dream." ✓ Ans- b
Waking up screaming from sleep at night indicates sleep terrors. The nurse
should advise the parents to observe the child and intervene only if there is a
risk for injury. Reading a story before bedtime helps to calm the child before
sleeping, but it does not ensure that the child will not have a sleep terror. There
is no need for professional counseling, because sleep terrors are a common
phenomenon in preschool-age children. The child is not aware of anybody's
presence during a sleep terror, so it is not appropriate to wake up the child; this
may cause the child to scream and thrash more.
Question 22
A client who was forced into early retirement is found to have severe
depression. The client says, "I feel useless, and I've got nothing to do." What is
the best initial response by the nurse?
A. ”Tell me more about feeling useless."
B. "Volunteering can help you fill your time."
C. "Your illness is adding to your current feelings."
D. "Let's talk about what you'd like to be doing right now." ✓ Ans- a
An open-ended response encourages further discussion and allows
exploration of feelings. Telling the client that volunteering will help pass the
time ignores the client's feelings. The depression is not adding to the feelings;
the feelings are causing the depression. Asking the client to talk about what
the client would rather be doing ignores the client's feelings.
Question 23
What characteristic is most essential for the nurse caring for a client undergoing
mental health care?
A. Empathy
B. Sympathy
C. Organization
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D. Authoritarianism ✓ Ans- a
Empathy—understanding and to some extent sharing the emotions of another
— encourages the expression of feelings. Empathy is an essential tool in caring
for emotionally ill clients. Sympathy, or feeling sorry for someone, may further
decrease the client's feelings of self-worth. Although organization may help the
client accept limits and organize activities, it is not as important as empathy. An
authoritarian approach will emphasize the client's weak ego and lack of self-
esteem.
Question 24
When visiting hours are over, a nurse approaches a client with paranoid
schizophrenia, who shouts, "You're the one that made my lover leave me."
What conclusion does the nurse make about the client?
A. The patient is disoriented.
B. The patient is actively hallucinating.
C. The patient feels a sense of vulnerability.
D. The patient needs to have limits set after calming down. ✓ Ans- c
The client's low self-esteem precipitates doubt of the lover's feelings, creating
a sense of vulnerability. This statement reflects the client's low self-esteem,
which is projected onto the nurse as part of the delusion. The client's
statements do not reflect disorientation but instead reflect false beliefs, which
are common in clients with paranoid schizophrenia. The client's statements do
not represent hallucinations because they are not false sensory perceptions.
Setting limits after the fact is not effective in any situation; limits must be set
when the problem occurs.
Question 24
During a survey, the community nurse meets a client who has not visited a
gynecologist after the birth of her second child. The client says that her
mother or sister never had annual gynecologic examinations. Which factor is
influencing the client's health practice?
A. Spiritual belief
B. Family practices
C. Emotional factors
D. Cultural background ✓ Ans- b
Family practices influence the client's perception of the seriousness of
diseases. The client does not feel the need to seek preventive care measures
because no family member practices preventive care. The client is not
D. Authoritarianism ✓ Ans- a
Empathy—understanding and to some extent sharing the emotions of another
— encourages the expression of feelings. Empathy is an essential tool in caring
for emotionally ill clients. Sympathy, or feeling sorry for someone, may further
decrease the client's feelings of self-worth. Although organization may help the
client accept limits and organize activities, it is not as important as empathy. An
authoritarian approach will emphasize the client's weak ego and lack of self-
esteem.
Question 24
When visiting hours are over, a nurse approaches a client with paranoid
schizophrenia, who shouts, "You're the one that made my lover leave me."
What conclusion does the nurse make about the client?
A. The patient is disoriented.
B. The patient is actively hallucinating.
C. The patient feels a sense of vulnerability.
D. The patient needs to have limits set after calming down. ✓ Ans- c
The client's low self-esteem precipitates doubt of the lover's feelings, creating
a sense of vulnerability. This statement reflects the client's low self-esteem,
which is projected onto the nurse as part of the delusion. The client's
statements do not reflect disorientation but instead reflect false beliefs, which
are common in clients with paranoid schizophrenia. The client's statements do
not represent hallucinations because they are not false sensory perceptions.
Setting limits after the fact is not effective in any situation; limits must be set
when the problem occurs.
Question 24
During a survey, the community nurse meets a client who has not visited a
gynecologist after the birth of her second child. The client says that her
mother or sister never had annual gynecologic examinations. Which factor is
influencing the client's health practice?
A. Spiritual belief
B. Family practices
C. Emotional factors
D. Cultural background ✓ Ans- b
Family practices influence the client's perception of the seriousness of
diseases. The client does not feel the need to seek preventive care measures
because no family member practices preventive care. The client is not
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influenced by spiritual beliefs in this instance. An individual's spiritual beliefs
and religious practices may restrict the use of certain forms of medical
treatment. Emotional factors such as stress, depression, or fear may influence
an individual's health practice; however, this client does not show signs of
being affected by emotional factors. The client is said to be influenced by
cultural background if he or she follows certain beliefs about the causes of
illness and uses customary practices to restore health.
Question 25
A client tells the nurse, "A man is speaking to me from the corner of the room.
Can you hear him?" How should the nurse respond?
A. ”What's he saying to you? Does it make any sense?"
B. "Yes, I hear him, but I can't understand what he's saying."
C. "I don't hear him. There's no one in the corner of the room."
D. "No, I don't hear him, but is it making you uncomfortable to hear him?" ✓ Ans- d
The statement "No, I don't hear him, but is it making you uncomfortable to
hear him?" points out reality, identifies potential feelings, and prevents the
nurse from supporting the hallucination. Asking what the man is saying to the
client and whether it makes any sense is nontherapeutic because it supports
and focuses on the hallucination. "Yes, I hear him, but I can't understand what
he is saying" is nontherapeutic because it supports and focuses on the
hallucination; also, it is not truthful. Although denying hearing the voice and
pointing out that there is no one else in the room points out reality, this
statement does not focus on the client's feelings.
Question 26
What is the priority nursing objective of the therapeutic psychiatric environment
for a confused client?
A. Helping the client relate to others
B. Making the hospital atmosphere more homelike
C. Helping the client become accepted in a controlled setting
D. Maintaining the highest level of safe, independent function ✓ Ans- d
The therapeutic milieu is directed toward helping the client develop effective
ways of functioning safely and independently. Helping the client relate to others
is one small part of the overall objectives. The therapeutic milieu allows some
items from home to make the client less anxious; however, the objective is not
to duplicate a home situation. Helping the client become accepted in a
controlled setting is a worthwhile objective but not as important as working
toward the maximal degree of safe, independent function.
influenced by spiritual beliefs in this instance. An individual's spiritual beliefs
and religious practices may restrict the use of certain forms of medical
treatment. Emotional factors such as stress, depression, or fear may influence
an individual's health practice; however, this client does not show signs of
being affected by emotional factors. The client is said to be influenced by
cultural background if he or she follows certain beliefs about the causes of
illness and uses customary practices to restore health.
Question 25
A client tells the nurse, "A man is speaking to me from the corner of the room.
Can you hear him?" How should the nurse respond?
A. ”What's he saying to you? Does it make any sense?"
B. "Yes, I hear him, but I can't understand what he's saying."
C. "I don't hear him. There's no one in the corner of the room."
D. "No, I don't hear him, but is it making you uncomfortable to hear him?" ✓ Ans- d
The statement "No, I don't hear him, but is it making you uncomfortable to
hear him?" points out reality, identifies potential feelings, and prevents the
nurse from supporting the hallucination. Asking what the man is saying to the
client and whether it makes any sense is nontherapeutic because it supports
and focuses on the hallucination. "Yes, I hear him, but I can't understand what
he is saying" is nontherapeutic because it supports and focuses on the
hallucination; also, it is not truthful. Although denying hearing the voice and
pointing out that there is no one else in the room points out reality, this
statement does not focus on the client's feelings.
Question 26
What is the priority nursing objective of the therapeutic psychiatric environment
for a confused client?
A. Helping the client relate to others
B. Making the hospital atmosphere more homelike
C. Helping the client become accepted in a controlled setting
D. Maintaining the highest level of safe, independent function ✓ Ans- d
The therapeutic milieu is directed toward helping the client develop effective
ways of functioning safely and independently. Helping the client relate to others
is one small part of the overall objectives. The therapeutic milieu allows some
items from home to make the client less anxious; however, the objective is not
to duplicate a home situation. Helping the client become accepted in a
controlled setting is a worthwhile objective but not as important as working
toward the maximal degree of safe, independent function.
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Question 27
Before an amniocentesis, both parents express anxiety about the fetus's safety
during the test. Which nursing intervention is most appropriate in promoting
the parents' ability to cope?
A. Initiating a parent-primary healthcare provider conference
B. Reassuring them that the procedure is safe
C. Explaining the procedure, step by step
D. Arranging for the father to be present during the test ✓ Ans- c
Giving the parents information about what to expect during the procedure will
help allay their fears and encourage their cooperation. The nurse should be
able to provide information and interpretation of procedures for clients; a delay
in answering questions may increase a client's concerns. Amniocentesis is a
low-risk procedure; however, some complications may occur. If the father is
uninformed, viewing the procedure may increase his anxiety, even though his
presence may be comforting to the mother.
Question 28
A young client who has just lost her first job comes to the mental health clinic
very upset and says, "I just start crying without any reason and without any
warning." How should the nurse respond initially?
A. ”Do you know what makes you cry?"
B. "Most of us need to cry from time to time."
C. "Crying unexpectedly can be very upsetting."
D. "Are you having any other problems at this time?" ✓ Ans- c
The response "Crying unexpectedly can be very upsetting" identifies the
client's feelings. Asking, "Do you know what makes you cry?" is an unrealistic
question; the cause of anxiety may not be known. "Most of us need to cry from
time to time" moves the focus away from the client. "Are you having any other
problems at this time?" disregards the client's comment; it is a direct question
that may impede communication.
Question 29
A client is admitted to the hospital with the diagnosis of severe anxiety. What
should the nurse's plan of care for a client with an anxiety disorder include?
A. Promoting the suppression of anger by the client
B. Supporting the verbalization of feelings by the client
C. Encouraging the client to limit anxiety-related behaviors
D. Restricting the involvement of the client's family during the acute phase ✓ Ans- b
Question 27
Before an amniocentesis, both parents express anxiety about the fetus's safety
during the test. Which nursing intervention is most appropriate in promoting
the parents' ability to cope?
A. Initiating a parent-primary healthcare provider conference
B. Reassuring them that the procedure is safe
C. Explaining the procedure, step by step
D. Arranging for the father to be present during the test ✓ Ans- c
Giving the parents information about what to expect during the procedure will
help allay their fears and encourage their cooperation. The nurse should be
able to provide information and interpretation of procedures for clients; a delay
in answering questions may increase a client's concerns. Amniocentesis is a
low-risk procedure; however, some complications may occur. If the father is
uninformed, viewing the procedure may increase his anxiety, even though his
presence may be comforting to the mother.
Question 28
A young client who has just lost her first job comes to the mental health clinic
very upset and says, "I just start crying without any reason and without any
warning." How should the nurse respond initially?
A. ”Do you know what makes you cry?"
B. "Most of us need to cry from time to time."
C. "Crying unexpectedly can be very upsetting."
D. "Are you having any other problems at this time?" ✓ Ans- c
The response "Crying unexpectedly can be very upsetting" identifies the
client's feelings. Asking, "Do you know what makes you cry?" is an unrealistic
question; the cause of anxiety may not be known. "Most of us need to cry from
time to time" moves the focus away from the client. "Are you having any other
problems at this time?" disregards the client's comment; it is a direct question
that may impede communication.
Question 29
A client is admitted to the hospital with the diagnosis of severe anxiety. What
should the nurse's plan of care for a client with an anxiety disorder include?
A. Promoting the suppression of anger by the client
B. Supporting the verbalization of feelings by the client
C. Encouraging the client to limit anxiety-related behaviors
D. Restricting the involvement of the client's family during the acute phase ✓ Ans- b
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Freedom to ventilate feelings serves as a safety valve to reduce anxiety. The
suppression of anger may increase the client's anxiety. Encouraging the client to limit
anxiety-related behaviors is not therapeutic; it may increase the anxiety that the client
is feeling.
Restricting the involvement of the client's family during the acute phase may or
may not be helpful; the client's family may provide support to the client.
Question 30
Windows in the recreation room of the adolescent psychiatric unit have been
broken on numerous occasions. After a group discussion one of the adolescents
confides that another adolescent client broke them. What should the nurse do
when using an assertive intervention instead of aggressive confrontation?
A. Confront the adolescent openly in the group, using a controlled voice and maintaining
direct eye contact.
B. Knock on the door of the adolescent's room and ask whether the adolescent would
come out to talk about the situation.
C. Approach the adolescent when the client is alone and, after making direct eye contact,
inquire about the involvement in these incidents.
D. Use a trusting approach toward the adolescent and imply that the staff doubts the
adolescent's involvement but requests a denial for the record. ✓ Ans- c
A private confrontation with presentation of reported facts allows verification; a
calm, direct manner is most assertive. Confronting the adolescent openly in the
group, using a controlled voice and maintaining direct eye contact, is
aggressive confrontation, not assertive intervention. Knocking on the door of
the adolescent's room and asking whether the adolescent would come out to
talk about the situation places control in the hands of the client rather than the
nurse, and this may lead to aggressive confrontation. Using a trusting approach
toward the adolescent and implying that the staff doubts the adolescent's
involvement but requests a denial for the record is not assertive intervention; it
is manipulation and is not truthful.
Question 31
A 6-year-old child with autism is nonverbal and makes limited eye contact. What
should the nurse do initially to promote social interaction?
A. Encourage the child to sing songs with the nurse.
B. Engage in parallel play while sitting next to the child.
C. Provide opportunities for the child to play with other children.
D. Use therapeutic holding when the child does not respond to verbal interactions. ✓
Ans- b Entering the child's world in a nonthreatening way helps promote trust and
eventual interaction with the nurse. Using therapeutic holding may be necessary when
a child initiates self-mutilating behaviors. Singing songs with the child participating or
providing opportunities for the child to play with other children is unrealistic at this
Freedom to ventilate feelings serves as a safety valve to reduce anxiety. The
suppression of anger may increase the client's anxiety. Encouraging the client to limit
anxiety-related behaviors is not therapeutic; it may increase the anxiety that the client
is feeling.
Restricting the involvement of the client's family during the acute phase may or
may not be helpful; the client's family may provide support to the client.
Question 30
Windows in the recreation room of the adolescent psychiatric unit have been
broken on numerous occasions. After a group discussion one of the adolescents
confides that another adolescent client broke them. What should the nurse do
when using an assertive intervention instead of aggressive confrontation?
A. Confront the adolescent openly in the group, using a controlled voice and maintaining
direct eye contact.
B. Knock on the door of the adolescent's room and ask whether the adolescent would
come out to talk about the situation.
C. Approach the adolescent when the client is alone and, after making direct eye contact,
inquire about the involvement in these incidents.
D. Use a trusting approach toward the adolescent and imply that the staff doubts the
adolescent's involvement but requests a denial for the record. ✓ Ans- c
A private confrontation with presentation of reported facts allows verification; a
calm, direct manner is most assertive. Confronting the adolescent openly in the
group, using a controlled voice and maintaining direct eye contact, is
aggressive confrontation, not assertive intervention. Knocking on the door of
the adolescent's room and asking whether the adolescent would come out to
talk about the situation places control in the hands of the client rather than the
nurse, and this may lead to aggressive confrontation. Using a trusting approach
toward the adolescent and implying that the staff doubts the adolescent's
involvement but requests a denial for the record is not assertive intervention; it
is manipulation and is not truthful.
Question 31
A 6-year-old child with autism is nonverbal and makes limited eye contact. What
should the nurse do initially to promote social interaction?
A. Encourage the child to sing songs with the nurse.
B. Engage in parallel play while sitting next to the child.
C. Provide opportunities for the child to play with other children.
D. Use therapeutic holding when the child does not respond to verbal interactions. ✓
Ans- b Entering the child's world in a nonthreatening way helps promote trust and
eventual interaction with the nurse. Using therapeutic holding may be necessary when
a child initiates self-mutilating behaviors. Singing songs with the child participating or
providing opportunities for the child to play with other children is unrealistic at this
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time; playing with others is a long-term objective.
Question 32
What is an important aspect of nursing care for a client exhibiting psychotic
patterns of thinking and behavior?
A. Helping keep the client oriented to reality
B. Involving the client in activities throughout the day
C. Helping the client understand that it is harmful to withdraw from situations
D. Encouraging the client to discuss why interacting with other people is being avoided ✓
Ans- a
Keeping the withdrawn client oriented to reality prevents further withdrawal
into a private world. A gradual involvement in selected activities is best. Helping
the client understand that it is harmful to withdraw from situations is futile at
this time. The psychotic client is unable to tell anyone the reason for avoiding
interaction with others.
Question 33
A nurse is volunteering on the community crisis hotline. What is the final
objective of the counseling process?
A. Reducing anxiety
B. Exploring feelings
C. Developing constructive coping skills
D. Accomplishing the debriefing process ✓ Ans- c
Past coping behaviors have been inadequate in resolving the current crisis; new
coping skills are needed to manage anxiety-producing conflicts. Reduction of
anxiety is an early objective. Exploration of feelings is an immediate objective.
Accomplishment of the debriefing process is an early objective.
Question 34
An infant is born with a bilateral cleft palate. Plans are made to begin
reconstruction immediately. What nursing intervention should be included to
promote parent-infant attachment?
A. Demonstrating positive acceptance of the infant
B. Placing the infant in a nursery away from view of the general public
C. Explaining to the parents that the infant will look normal after the surgery
D. Encouraging the parents to limit contact with the infant until after the surgery ✓
Ans- a
By demonstrating acceptance of the infant, without regard for the defect, the
nurse acts as a role model for the parents, thereby encouraging their
acceptance. Infants with cleft palates can remain in the newborn nursery; they
time; playing with others is a long-term objective.
Question 32
What is an important aspect of nursing care for a client exhibiting psychotic
patterns of thinking and behavior?
A. Helping keep the client oriented to reality
B. Involving the client in activities throughout the day
C. Helping the client understand that it is harmful to withdraw from situations
D. Encouraging the client to discuss why interacting with other people is being avoided ✓
Ans- a
Keeping the withdrawn client oriented to reality prevents further withdrawal
into a private world. A gradual involvement in selected activities is best. Helping
the client understand that it is harmful to withdraw from situations is futile at
this time. The psychotic client is unable to tell anyone the reason for avoiding
interaction with others.
Question 33
A nurse is volunteering on the community crisis hotline. What is the final
objective of the counseling process?
A. Reducing anxiety
B. Exploring feelings
C. Developing constructive coping skills
D. Accomplishing the debriefing process ✓ Ans- c
Past coping behaviors have been inadequate in resolving the current crisis; new
coping skills are needed to manage anxiety-producing conflicts. Reduction of
anxiety is an early objective. Exploration of feelings is an immediate objective.
Accomplishment of the debriefing process is an early objective.
Question 34
An infant is born with a bilateral cleft palate. Plans are made to begin
reconstruction immediately. What nursing intervention should be included to
promote parent-infant attachment?
A. Demonstrating positive acceptance of the infant
B. Placing the infant in a nursery away from view of the general public
C. Explaining to the parents that the infant will look normal after the surgery
D. Encouraging the parents to limit contact with the infant until after the surgery ✓
Ans- a
By demonstrating acceptance of the infant, without regard for the defect, the
nurse acts as a role model for the parents, thereby encouraging their
acceptance. Infants with cleft palates can remain in the newborn nursery; they
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Health Education Systems, Inc.