1. A nurse is caring for an adult client who has visible injuries as a result of intimate partner

violence. Which of the following actions should the nurse take?

Answer: Encourage the client to develop a safety plan

2. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of

cocaine use. The nurse should identify that which of the following manifestations is an indicator

of the client’s use of this substance?

Answer: Hypertension

3. A nurse in a mental health facility is caring for a client who has dementia. The client’s

agitation is increasing. Which of the following actions should the nurse take first?

Answer: Offer diversionary activities

4. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and

begins pacing at the end of the hallway with clenched fists. Which of the following actions should

the nurse take first?

Answer: Determine the client’s intentions

5. A nurse is reinforcing discharge teaching with a client who has a new prescription for alprazolam.

Which of the following instructions is the priority for the nurse to include?

Answer: Do not drive until your reaction to the medication is determined

6. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news

report about military action comes on the television, the client says to the nurse, “My youngest child

died 6 months ago while serving in the military.” Which of the following responsesshould the nurse

make?

Answer:

-This must be very difficult time for you

-Your child’s death must be a terrible loss

-Tell me something you remember about your child

7. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania,

Which of the following interventions should the nurse include to improve the nutritional status of the

client?

Answer: Have the client’s favorite snacks available at all times.

8. A nurse is collecting data from a client who has paranoid personality disorder. Which of the

following manifestations should the nurse expect?

Answer: Projects blame onto others

9. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a

client begins to shout using aggressive language. Which of the following statements should the

nurse make to the client?