1. A nurse is caring for a client whose child has a terminal illness. The client requests

information about how to deal with the upcoming loss. Which of the following statements

should the nurse make

a. "It is not uncommon to feel angry toward yourself or others

Reason: Feelings of blame and anger towards oneself or others are an expected

reaction when a client is experiencing a loss.

2. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of

the following instructions should the nurse include in the teaching

a. "Take this medication with food

Reason: Lithium can cause GI distress and should be taken with food.

Recommended sodium intake 1500mg/day. Recommended 2000-3000ml/day fluids.

3. A nurse is planning care for four clients in a mental health facility. Which of the following

clients is at the greatest risk for injury when performing ADLs

a. A client who has severe Alzheimer's disease

Reason: Alzheimer's clients are typically confused with memory difficulties, tend to

wander and need ADL assistance.

4. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5?ove his

ideal body weight. Which of the following interventions should the nurse include in the plan

a. Identify the client's trigger foods

Reason: Nurse should identify trigger foods that initiate the client's binge and assist

the client to understand his thoughts and behavior that relate to the food

5. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of

the following family groups should the nurse identify as the highest potential for future child

abuse

a. A family where one or both parents witnessed intimate partner violence in the home

as children

Reason: Parents who witnessed intimate partner violence as a child are more likely

to become abusive.

6. A nurse is performing an admission assessment on a client and notices that the client

appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the

following actions should the nurse take first

a. Inform the client that her admission is confidential

Reason: According to EBP, Nurse should inform client about confidentiality during

orientation phase of nurse-client relationship