QUESTION 33 Which nursing intervention would the RN include in the plan of care for an autistic client with the nursing diagnosis of Self-mutilation?…


Which nursing intervention would the RN include in the plan of care for an autistic client with the nursing diagnosis of Self-mutilation?

a.           Set time limits for meals.

b.           Maintain a structured schedule of daily activities.

c.            Offer sympathy during episodes of self-mutilation.

d.           Rotate staff members who care for the client.


The RN is conducting a 15-minute mental health assessment for a client in the manic phase of Bipolar Disorder. What is the rationale for limiting the length of the assessment?

a.           Too many questions can lead to depression.

b.           A longer period of time may overstimulate the client.

c.            The client will feel pressured to keep talking.

d.           The client will lose interest if it is longer.


The RN is aware that which would occur if needs were not met during the latency stage of Freud’s development?

 a.          Disorganization, untidiness and destructiveness.

 b.          Identification with the opposite-gender parent.

 c.           Inability to trust others.

 d.          Inability to develop relationships with other children.


Which clinical manifestation will the RN expect to observe in a patient taking the medication disulfiram (Antabuse) who presents to the emergency room where a blood alcohol level of 125 mg/dL is obtained?

a.           Nausea and vomiting

b.           Sweating

c.            Headache

d.           Heart failure


Which behavior would the RN interpret as an inappropriate affect?

a.           Smiling when receiving news of a birth of a child.

b.           Crying when being told that the family pet has died.

c.            Reacting calmly when a child drops food on the floor.

 d.          Giggling while reading the news of a fatal car accident.


Which RN intervention is the priority when caring for a patient with Borderline Personality Disorder who displays occasional self-destructive behaviors?

a.           Place the patient under continuous observation.

 b.          Minimize physical activity to discourage violent impulses.

c.            Encourage the patient to explore triggers for the behaviors.

d.           Contact the healthcare provider for an order for restraints.


To create safe environment for a client with Alzheimer’s disease who wanders, the RN instructs the LPN to assist with which of the following interventions?

 a.          Encourage independence with preparing meals.

 b.          Provide an enclosed area for pacing.

 c.           Remove all diversions such as television and radio.

 d.          Maintain a varied schedule for meals and toileting.


Which nursing interventions are important for the RN to incorporate into a care plan for a client with an Obsessive-Compulsive Disorder? Select all that apply.

a.           Tell the patient to spend more time alone.

b.           Involve the patient in group therapy activities.

c.            Discourage physical activity as it might cause fatigue.

d.           Encourage journaling to sort out feelings.

 e.          Teach the patient to breathe slowly and deeply.  


What are the expected cycle of battering characteristics for a client who has been the victim of domestic violence for many years? Select all that apply.

 a.          Abuser has low tolerance for frustration.

 b.          Victim enjoys being abused.

 c.           Abuser fears that the partner will leave.

d.           Abuser is expected to stop being abusive.


A rural mother with a low birth-weight infant was charged with abusing her child. Which factor has been shown to be most predictive of the potential for child abuse?

 a.          Depressive symptoms

 b.          Lack of social support

 c.           Minimal financial resources

 d.          Isolation of rural environment


Which would be a common psychosocial expected outcome for a patient with any eating disorder?

a.           A positive body image.

b.           Effective physical mobility.

c.            Regular meal times.

d.           Weight change of ten pounds.

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