Violence
A nurse suspects child physical abuse. Which finding is most concerning?
A. Multiple bruises in different stages of healing
B. Bruises over bony prominences
C. Small abrasions on knees
D. Single bruise on shin
Answer: A
Rationale: Injuries in various stages of healing suggest repeated trauma.
A client with anorexia nervosa has a BMI of 15 and a heart rate of 48 bpm. What is the nurse’s priority?
A. Encourage high-calorie snacks
B. Monitor cardiac status
C. Discuss body image
D. Provide nutrition teaching
Answer: B
Rationale: Severe anorexia can cause bradycardia and cardiac instability. Physiological stability is the priority.
A child with ADHD has difficulty sitting still and frequently interrupts others. These behaviors are characteristic of:
A. Oppositional defiant disorder
B. Hyperactivity and impulsivity
C. Autism spectrum disorder
D. Conduct disorder
Answer: B
Rationale: ADHD is marked by inattention, hyperactivity, and impulsivity.
The nurse is helping a patient in crisis develop solutions. Which approach best reflects crisis intervention principles?
Answer: 2
The nurse needs to be creative and flexible in helping the patient solve problems. Although the nurse helps guide the patient, it is important to remember that the patient is ultimately in charge of their own life and decision-making. The patient must actively problem-solve with the nurse.
Which behavior by the nurse demonstrates active listening?
Answer: 1
Active listening involves carefully noting what the patient is saying verbally and nonverbally while monitoring one's own responses. It communicates that the patient is not alone and enhances self-esteem.
A child reports abuse and asks the nurse not to tell anyone. What is the nurse’s best response?
A. “I won’t tell anyone if you don’t want me to.”
B. “You should have told sooner.”
C. “I need to report this to keep you safe.”
D. “Let’s wait and see what happens.”
Answer: C
Rationale: Nurses are mandated reporters and must prioritize safety.
A client with anorexia nervosa states, “I feel fat even though everyone says I’m too thin.” This reflects:
A. Denial
B. Body image distortion
C. Binge behavior
D. Low self-esteem
Answer: B
Rationale: Distorted perception of body size is a hallmark of anorexia nervosa.
The nurse is teaching parents about methylphenidate (Ritalin) for ADHD. Which instruction is most important?
A. Give the medication at bedtime
B. Crush the extended-release tablets
C. Stop the medication abruptly if side effects occur
D. Monitor for decreased appetite
Answer: D
Rationale: Stimulants commonly suppress appetite and may affect growth.
A nurse working in the emergency department after a mass shooting begins experiencing anxiety and intrusive thoughts several days later. What should the nurse recognize?
Answer: 3
Nurses often suppress their own feelings to handle immediate situations and may react later with anxiety or shock. Supervisors should be aware of secondary traumatic stress and compassion fatigue. Debriefing and supportive networks are essential for nurses exposed to disaster situations.
A patient states, "My life is empty… It has no meaning." Which response demonstrates restating?
Answer: 4
Restating mirrors the patient's overt and covert messages by repeating the same key words the patient has just spoken. The purpose is to explore subjects that may be significant and encourage further discussion.
A patient has repeated ED visits for vague complaints and unexplained injuries. What is the most appropriate screening approach?
A. Ask about abuse only if the partner is present
B. Use direct, private, nonjudgmental questions
C. Avoid asking to prevent embarrassment
D. Report immediately without assessment
Answer: B
Rationale: IPV screening should occur privately with direct, supportive questions.
During a meal, a client with anorexia nervosa cuts food into tiny pieces and pushes it around the plate. What is the nurse’s best response?
A. Remove the tray
B. State, “You must eat everything.”
C. Encourage the client to take small bites and stay with them
D. Ignore the behavior
Answer: C
Rationale: Provide structured support during meals and encourage intake without power struggles.
Which nursing intervention is appropriate for a hospitalized child with autism?
A. Frequently change caregivers
B. Maintain a consistent routine
C. Encourage group play immediately
D. Use figurative language
Answer: B
Rationale: Children with ASD respond best to predictable routines and consistency.
Which type of crisis is characterized as not part of everyday life and impacts an entire community?
Answer:4
An adventitious crisis (or crisis of disaster) is not a common part of everyday life and is generally much larger in scale, impacting a community rather than just an individual. These include natural disasters, terrorist attacks, and mass violence events.
What is the primary characteristic that distinguishes a therapeutic relationship from a social relationship?
Answer: 3
The therapeutic relationship differs from a social relationship in that the nurse maximizes communication skills, understanding of human behavior, and personal strengths to enhance the patient's growth. The focus remains consistently on the patient's problems and needs, not the nurse's needs.
A client experiencing IPV says, “I’m planning to leave tonight.” What is the nurse’s priority?
A. Encourage reconciliation
B. Document and discharge
C. Call the partner
D. Develop a safety plan
Answer: D
Rationale: Leaving increases risk; safety planning is critical.
A client with bulimia nervosa has swollen cheeks and dental erosion. These findings are caused by:
A. Starvation
B. Dehydration
C. Self-induced vomiting
D. Excessive exercise
Answer: C
Rationale: Frequent vomiting causes parotid gland swelling and erosion of tooth enamel from stomach acid.
Which behavior is most consistent with autism spectrum disorder?
A. Frequent temper tantrums only
B. Excessive talking
C. Repetitive hand-flapping and strict routines
D. Stealing
Answer: C
Rationale: Restricted, repetitive behaviors and insistence on sameness are core ASD features.
After a tornado destroys part of a community, many survivors report confusion, difficulty making decisions, and sleep disturbances. The nurse recognizes these as:
Answer: 2
Victims of disaster commonly experience cognitive impairment (confusion, difficulty making decisions, intrusive memories), behavioral changes (substance use, difficulty functioning, sleep disturbances), and emotional issues. Early intervention is crucial to prevent stress-related disorders and chronic impairment.
A patient asks the nurse, "What should I do about my relationship problems?" What is the most therapeutic response?
Answer: 2
Giving advice fosters dependency and undermines the patient's sense of competence. It's more constructive to encourage critical thinking by helping the patient identify possible actions rather than providing solutions.
An older adult appears withdrawn and malnourished. The caregiver answers all questions and refuses to leave the room. What should the nurse do?
A. Accept the caregiver’s answers
B. Insist on speaking with the patient alone
C. Document and discharge
D. Ignore the behavior
Answer: B
Rationale: Private assessment is essential when abuse is suspected.
Which statement by a client with anorexia indicates improvement?
A. “I still think I’m overweight.”
B. "I exercised for 3 hours today."
C. “I skipped breakfast.”
D. “I ate lunch even though I felt anxious.”
Answer: D
Rationale: Eating despite anxiety demonstrates progress toward healthier behaviors.
A child with autism spectrum disorder avoids eye contact and prefers to play alone. This reflects difficulty with:
A. Social Communication
B. Fine motor skills
C. Memory
D. Intelligence
Answer: A
Rationale: ASD is characterized by deficits in social communication and interaction.
Which situation represents a situational crisis?
Answer: 3
A situational crisis arises from an external rather than internal source and is frequently unanticipated. Examples include loss of a job, death of a loved one, unwanted pregnancy, divorce, or severe illness.
What is the fundamental difference between assessment and therapeutic communication?
Answer: 2
Assessment is an information-gathering approach designed to meet the nurse's needs, whereas therapeutic communication meets the patient's needs. Both are important but serve different purposes.