A client with PTSD is triggered by loud noises. What intervention should the nurse implement?

Identify triggers and develop coping strategies

A client reports ongoing emotional abuse by a partner. What is the best nursing response?

"Abuse isn’t just physical. Let’s talk about your safety."

A client in an inpatient unit is attempting to elope. What is the nurse’s priority?

Block the exit and call security

A nurse is working in a community health clinic. Which population is considered vulnerable?

Unhoused individuals, Incarcerated individuals, Children in low-income households

A nurse is conducting a suicide risk assessment. Which finding indicates the highest risk for suicide?

A client who has access to lethal means and a clear plan

A nurse is teaching a family member of a client with Alzheimer’s disease. Which statement indicates understanding?

"I will use simple words and short sentences when speaking."

A client with depression states, "I don’t want to be here anymore." What is the nurse’s priority action?

Ask the client directly about suicidal thoughts

A nurse is caring for a client from an underserved community. What is the priority nursing action?

Advocate for equitable healthcare access

A nurse suspects elder abuse. What is the first action the nurse should take?

Report the suspicion to protective services

A nurse is caring for a client with schizophrenia who states "The government is watching me." What is the best response?

"Tell me more about what makes you feel this way."

The client is a danger to themselves or others

"Let’s discuss the impact of alcohol on your life."

A client experiencing severe anxiety is pacing the room. What is the best nursing action?

Walk with the client and provide reassurance

Develop a structured daily routine

Establish rapport and ensure safety

A nurse is caring for a client with PTSD. Which manifestation should the nurse expect?

Avoidance of trauma reminders, Hypervigilance, Flashbacks

. "Tell me more about the healing practices you use."

A nurse is planning health promotion for LGBTQIA+ youth. What should be included?

Resources for mental health support

A nurse is developing a health promotion program for an at-risk population. What should the nurse prioritize?

Improving access to mental health resources

Administer benzodiazepines as prescribed

A nurse is working with a client who lacks transportation to mental health services. What is the best intervention?

Suggest public transportation options

A client experiencing a panic attack states, "I feel like I’m going to die." What is the nurse’s priority action?

Encourage deep breathing techniques

"You seem overwhelmed. Can you tell me more?"

A nurse is educating a community about intimate partner violence (IPV). Which statement indicates understanding?

"Abuse victims should be encouraged to make a safety plan."

Report suspected abuse to child protective services

A client with PTSD is experiencing a flashback. What is the nurse’s first action?

Orient the client to the present moment

"Tell me more about why you believe that."

A nurse is discharging a client with a history of suicide attempts. What should the nurse include in the safety plan?

Warning signs of suicidal ideation, Emergency contacts, Coping strategies

A client states, "No one cares about me." What is the most appropriate nursing response?

"I care about you, and I’m here to listen."

A nurse is documenting an incident where restraints were used. What must be included?

Alternative interventions attempted, Reason for restraint use, Length of time restraints will remain, Client's response

A nurse is providing education on mental health resources in a rural community. Which intervention is most effective?

Establishing telehealth counseling services

A nurse is assessing a client with severe depression. Which statement requires immediate intervention?

"I just wish I could disappear forever."

"CBT will help me change my negative thought patterns."

A nurse is working with an LGBTQIA+ client. What is the most appropriate nursing intervention?

Ask the client how they would like to be addressed

Maintaining fulfilling relationships, Demonstrating appropriate coping mechanisms, Adapting to stressors effectively

A nurse is prioritizing care for a client with major depressive disorder. Which intervention should be implemented first

Assess the client for suicidal ideation

A client with severe depression refuses to attend therapy sessions. What is the nurse’s best response?

"Let’s discuss your feelings about attending therapy."

A nurse is assessing a client who has experienced intimate partner violence. What is the priority nursing action?

Develop a safety plan with the client

Which action should the nurse take first when a client with schizophrenia begins to display aggressive behavior?

Use therapeutic communication to de-escalate the situation

A client is hyperventilating during a panic attack. What is the nurse’s priority action?

Encourage deep breathing techniques

"I take my anger out on my family instead of my boss."

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315 Exam 1

70 termsStudBud Administration21 plays

Made by Alexis McGuinness

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Questions 70

Answers

1
A client with PTSD is triggered by loud noises. What intervention should the nurse implement?
Expose the client to loud noises gradually
Encourage the client to ignore the noise
Identify triggers and develop coping strategies
Tell the client their reaction is irrational
2
A client reports ongoing emotional abuse by a partner. What is the best nursing response?
"Maybe things will get better with time."
"At least they aren’t physically hurting you."
"You should leave immediately."
"Abuse isn’t just physical. Let’s talk about your safety."
3
A client in an inpatient unit is attempting to elope. What is the nurse’s priority?
Allow the client to leave freely
Ask the client to stop
Shout to alert other staff
Block the exit and call security
4
A nurse is working in a community health clinic. Which population is considered vulnerable?
Unhoused individuals
Incarcerated individuals
Children in low-income households
Middle-aged adults with stable employment
Individuals with private health insurance
5
A nurse is conducting a suicide risk assessment. Which finding indicates the highest risk for suicide?
A client with a vague plan but no means to carry it out
A client who has occasional suicidal thoughts but no intent
A client who has access to lethal means and a clear plan
A client who states they feel hopeless but denies suicidal intent
6
A nurse is teaching a family member of a client with Alzheimer’s disease. Which statement indicates understanding?
"I should avoid reminiscing, as it may confuse them more."
"It’s best to challenge my loved one’s memory to help them improve."
"I will use simple words and short sentences when speaking."
"I should correct my loved one when they forget things."
7
A client with depression states, "I don’t want to be here anymore." What is the nurse’s priority action?
Reassure the client that things will improve
Encourage the client to journal their feelings
Offer the client a distraction activity
Ask the client directly about suicidal thoughts
8
A nurse is caring for a client from an underserved community. What is the priority nursing action?
Limit health teaching due to resource scarcity
Assume the client has low health literacy
Advocate for equitable healthcare access
Encourage reliance on family support only
9
A nurse suspects elder abuse. What is the first action the nurse should take?
Confront the suspected abuser
Report the suspicion to protective services
Document findings in the medical record
Ask the client to discuss the abuse
10
A nurse is caring for a client with schizophrenia who states "The government is watching me." What is the best response?
"That’s not true. You’re imagining things."
"You should stop thinking that way."
"I agree, the government monitors many people."
"Tell me more about what makes you feel this way."
11
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The client has a history of noncompliance
The client is mildly confused
The client is a danger to themselves or others
The client refuses treatment but has no safety risk
12
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"You should feel guilty about your drinking."
"Let’s discuss the impact of alcohol on your life."
"You need to quit drinking immediately."
"If you don’t stop drinking, I can’t help you."
13
A nurse is working with a survivor of childhood trauma. What intervention supports trauma-informed care?
Establishing trust and safety
Encouraging the client to "move on"
Pushing the client to recall all details
Minimizing discussion of past trauma
14
A client experiencing severe anxiety is pacing the room. What is the best nursing action?
Walk with the client and provide reassurance
Offer PRN medication immediately
Ask the client to explain their anxiety
Encourage the client to sit down and relax
15
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Encourage daytime naps
Suggest avoiding social interactions
Develop a structured daily routine
Recommend increased caffeine intake
16
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Educate the client on mental health treatment
Refer the client to a psychiatrist
Establish rapport and ensure safety
Obtain a detailed psychiatric history
17
Which social determinant has the greatest impact on mental health outcomes?
Socioeconomic status
Education level
Geographic location
Access to nutritious food
18
A nurse is caring for a client with PTSD. Which manifestation should the nurse expect?
Increased social engagement
Avoidance of trauma reminders
Hypervigilance
Flashbacks
Reduced startle response
19
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Nonmaleficence
Autonomy
Beneficence
Veracity
20
A nurse is caring for a client in alcohol withdrawal. Which symptom requires immediate intervention?
Anxiety
Profuse sweating
Mild tremors
Hallucinations
21
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"You should follow only evidence-based treatments."
. "Tell me more about the healing practices you use."
"Traditional healing has no scientific basis."
"You must take your prescribed medications instead."
22
A nurse is planning health promotion for LGBTQIA+ youth. What should be included?
Resources for mental health support
Referral to conversion therapy programs
Encouragement to avoid discussing gender identity
Limiting access to gender-affirming care
23
A nurse is developing a health promotion program for an at-risk population. What should the nurse prioritize?
Improving access to mental health resources
Reducing stigma surrounding mental illness
Encouraging physical activity
Teaching stress management techniques
24
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Administer benzodiazepines as prescribed
Provide a low-stimulation environment
Reorient the client frequently
Encourage increased fluid intake
25
A nurse is working with a client who lacks transportation to mental health services. What is the best intervention?
Suggest public transportation options
Advise the client to attend fewer appointments
Recommend self-management techniques only
Encourage the client to find a closer provider
26
A client experiencing a panic attack states, "I feel like I’m going to die." What is the nurse’s priority action?
Encourage deep breathing techniques
Explain that the client is safe
Offer the client a distraction
Ask the client to describe their feelings
27
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"Many people experience this. It’s normal."
"You should try to think more positively."
"Everything will be fine soon."
"You seem overwhelmed. Can you tell me more?"
28
A nurse is educating a community about intimate partner violence (IPV). Which statement indicates understanding?
"Only physical abuse requires intervention."
"Leaving an abusive relationship is easy."
"IPV affects only certain socioeconomic groups."
"Abuse victims should be encouraged to make a safety plan."
29
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Ask the caregiver directly if they are abusing the child
Document findings and monitor the child closely
Report suspected abuse to child protective services
Encourage the child to disclose details of the abuse
30
A client with PTSD is experiencing a flashback. What is the nurse’s first action?
Orient the client to the present moment
Ask the client to describe the traumatic event
Leave the client alone to process their emotions
Encourage the client to ignore the flashback
31
A nurse is caring for a client experiencing hallucinations. What is the priority intervention?
Validate the hallucination as real
Explore the content of the hallucinations
Leave the client alone to process
Encourage reality orientation
32
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"That’s not true. Your food is safe to eat."
"I will have someone else taste your food first."
"Tell me more about why you believe that."
"You must eat, or I’ll have to notify the doctor."
33
A nurse is discharging a client with a history of suicide attempts. What should the nurse include in the safety plan?
Access to lethal means
Warning signs of suicidal ideation
Emergency contacts
Social isolation strategies
Coping strategies
34
A client experiencing opioid withdrawal is admitted to the mental health unit. What symptom should the nurse expect?
Excessive sedation
Hypothermia
Hypertension
Bradycardia
35
A client states, "No one cares about me." What is the most appropriate nursing response?
"You shouldn’t think like that."
"Why do you feel that way?"
"I care about you, and I’m here to listen."
"That’s not true. You have family who loves you."
36
A client with borderline personality disorder exhibits self-harming behavior. What is the priority nursing intervention?
Encourage group therapy immediately
Set firm limits and boundaries
Restrict all client interactions
Ignore attention-seeking behaviors
37
A nurse is documenting an incident where restraints were used. What must be included?
Family's opinion about restraint use
Alternative interventions attempted
Reason for restraint use
Length of time restraints will remain
Client's response
38
A nurse is providing education on mental health resources in a rural community. Which intervention is most effective?
Reducing the number of crisis centers
Encouraging clients to travel for psychiatric care
Limiting mental health services to primary care clinics
Establishing telehealth counseling services
39
A nurse is assessing a client with severe depression. Which statement requires immediate intervention?
"I feel like nothing will ever get better."
"I don’t enjoy things I used to love."
"I just wish I could disappear forever."
"I have no appetite these days."
40
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Ask the client to ignore the voices
Implement 1:1 supervision
Provide reality orientation
Encourage the client to rest
41
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"CBT will help me change my negative thought patterns."
"CBT will eliminate my anxiety permanently."
"I will need medication for therapy to work."
"CBT is only useful for depression, not anxiety."
42
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Dry mouth
Weight gain
Increased suicidal thoughts
Insomnia
43
A nurse is working with an incarcerated individual diagnosed with schizophrenia. What is the primary concern?
Ensuring medication adherence
Encouraging employment post-release
Providing financial resources
Teaching anger management
44
A nurse is working with an LGBTQIA+ client. What is the most appropriate nursing intervention?
Ask the client how they would like to be addressed
Assume the client prefers gender-neutral pronouns
Avoid discussing gender identity
Encourage the client to conform to societal norms
45
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Maintaining fulfilling relationships
Having a rigid belief system
Avoiding all negative emotions
Demonstrating appropriate coping mechanisms
Adapting to stressors effectively
46
A nurse is prioritizing care for a client with major depressive disorder. Which intervention should be implemented first
Refer the client to a support group
Assess the client for suicidal ideation
Encourage the client to express feelings
Provide information about antidepressants
47
A client with severe depression refuses to attend therapy sessions. What is the nurse’s best response?
"You have to attend, or you won’t get better."
"Skipping therapy means you don’t want to improve."
"You should go because your provider recommends it."
"Let’s discuss your feelings about attending therapy."
48
A nurse is assessing a client who has experienced intimate partner violence. What is the priority nursing action?
Contact law enforcement immediately
Develop a safety plan with the client
Provide pamphlets on domestic violence shelters
Encourage the client to leave the relationship
49
Which action should the nurse take first when a client with schizophrenia begins to display aggressive behavior?
Offer the client a PRN medication
Restrain the client immediately
Use therapeutic communication to de-escalate the situation
Place the client in seclusion
50
A client is hyperventilating during a panic attack. What is the nurse’s priority action?
Ask the client to describe their fears
Encourage deep breathing techniques
Offer a sedative immediately
Reassure the client that they are safe
51
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"I pretend my trauma never happened."
"I behave childishly when I’m upset."
"I refuse to believe I have a problem."
"I take my anger out on my family instead of my boss."
52
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Decreased risk of chronic illness
Increased risk of mental health disorders
Lower likelihood of substance use
Improved emotional resilience
53
A nurse is caring for an older adult client with depression. Which factor increases their risk for suicide?
Increased appetite
Frequent laughter
Social isolation
Active family involvement
54
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Battery
False imprisonment
Negligence
Defamation
55
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The client is at risk of harming themselves
The client does not have social support
The client has a history of depression
The client lacks financial resources for care
56
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"I will stop taking my medication once I feel better."
"Even if I feel fine, I need to take my medication daily."
"I can skip doses if I’m not having mood swings."
"I should avoid caffeine while on this medication."
57
Which intervention should the nurse include in the plan of care for a client with PTSD?
Offer support groups for trauma survivors
Avoid all reminders of the traumatic event
Minimize discussion of the trauma
Encourage use of grounding techniques
Provide a structured routine
58
A nurse is de-escalating a violent client. Which approach is most appropriate?
Leave the client alone
Use a calm and non-threatening voice
Physically restrain the client immediately
Speak loudly to establish control
59
A client reports hearing voices that tell them they are worthless. What is the nurse’s priority intervention?
Ignore the hallucination to prevent reinforcement
Encourage the client to isolate from others
Tell the client the voices aren’t real
Ask the client what the voices are saying
60
A client is receiving treatment for opioid addiction. Which medication is used to reduce cravings?
Diazepam
Methadone
Flumazenil
Naloxone
61
A client with depression states, "I don’t think I can go on anymore." What is the nurse’s best response?
"Do you have a plan to harm yourself?"
"You shouldn’t think that way."
"Try to focus on positive things."
"You’ll feel better soon."
62
A nurse is assessing a client in heroin withdrawal. Which symptom is expected?
Hypotension
Dilated pupils
Excessive sedation
Bradycardia
63
A nurse is caring for a client under involuntary psychiatric hold. Which action is appropriate?
Prevent family visits
Deny the client all phone calls
Assess the client’s right to refuse treatment
Allow the client to refuse all medications
64
A nurse is caring for a migrant farmworker with limited access to healthcare. What is an appropriate intervention?
Encourage the client to relocate for better care
Offer mobile health clinic resources
Provide a list of high-cost specialists
Refer the client to emergency services only
65
A client with anxiety is prescribed buspirone. Which statement indicates understanding of the medication?
"I should take this only when I feel anxious."
"I can drink alcohol while on this medication."
"This medication will start working right away."
"I need to take this daily for it to be effective."
66
A nurse is caring for a client with PTSD. Which statement indicates the client is improving?
"I avoid thinking about the trauma."
"I feel more comfortable talking about my trauma."
"I still have nightmares every night."
"I still feel constantly on edge."
67
A client is diagnosed with generalized anxiety disorder. Which nursing intervention is the highest priority?
Administering PRN anxiolytic medication
Teaching relaxation techniques
Ensuring the client’s safety
Encouraging social interactions
68
A client is admitted with acute mania. What is the most appropriate nursing action?
Provide high-calorie finger foods
Allow the client to pace freely in the hallway
Engage the client in decision-making
Encourage participation in group therapy
69
A nurse applies physical restraints on a client. Which action is required?
Restrain the client at the first sign of agitation
Leave the restraints on until the client is completely calm
Avoid assessing circulation while restraints are in place
Document the client’s behavior and interventions used
70
A community health nurse is developing a program for suicide prevention in adolescents What should the nurse prioritize?
Restricting social media access
Encouraging adolescents to handle stress alone
Educating parents and teachers on warning signs
Increasing law enforcement presence in schools

315 Exam 1 Flashcards | StudBud