Extract:

Question 1 of 5

A nurse is caring for a client who asks the nurse, 'May I please have your home address so that I can send you a note after I get home?' Which of the following responses should the nurse give?

A. Sure, I will write it down for you.B. I know you are looking forward to being at home again and having a normal routine.C. Thank you for your kind words. Unfortunately, I am not allowed to share my home address by policy of the hospital.D. Absolutely not! We are not allowed to give out our personal information!

Correct Answer: C

Rationale: This response politely declines the client’s request while explaining that hospital policy prohibits sharing personal information, maintaining professionalism and boundaries. Providing the address compromises privacy, redirecting to the client’s routine avoids the request, and a harsh refusal may distress the client unnecessarily.

Question 2 of 5

A nurse is caring for a client who has a serious mental illness. The client states, 'Kiss me baby! You know you want to!' Which of the following should the nurse identify as the priority to address?

A. The client's blood pressure is 140/90 mm HgB. The client's heart rate is 88/minC. The client is wearing a heavy coat and scarf in warm weatherD. The client's statement to the nurse

Correct Answer: D

Rationale: The client’s inappropriate and suggestive statement indicates a lack of understanding of professional boundaries, which is a priority to address to maintain a safe and therapeutic environment. Elevated blood pressure, heart rate, and inappropriate clothing are important but secondary concerns, as they do not pose an immediate risk to the therapeutic relationship or safety.

Question 3 of 5

A nurse on a mental health unit is caring for a client who has a new diagnosis of borderline personality disorder. The client states, 'I will just see my regular doctor at my annual checkup after I am discharged.' Which of the following responses should the nurse make?

A. You should follow up with your regular doctor in the next few months so they can manage your new diagnosis.B. You have made such great progress here. I can see why you feel so well.C. It is recommended that you receive follow-up care from a mental health provider after you are discharged.D. Since you have such a good relationship with your family practice provider, you do not need to see a mental health provider.

Correct Answer: C

Rationale: Borderline personality disorder requires specialized mental health care, such as from a psychiatrist or psychologist, for ongoing management. Encouraging follow-up with a mental health provider ensures appropriate care. Relying solely on a regular doctor, praising progress without addressing follow-up, or dismissing the need for specialized care are inadequate responses.

Question 4 of 5

A nurse is discussing coping strategies with a client who has experienced a recent loss. Which of the following strategies should the nurse recommend?

A. Suppress emotions to avoid distress.B. Engage in regular physical activity.C. Avoid discussing the loss with others.D. Use alcohol to relax in the evenings.

Correct Answer: B

Rationale: Engaging in regular physical activity can help manage grief by reducing stress and improving mood through endorphin release. Suppressing emotions, avoiding discussion, or using alcohol are maladaptive and can worsen emotional health.

Question 5 of 5

A nurse is caring for a client who has been prescribed a benzodiazepine for anxiety. Which of the following instructions should the nurse include in the client’s teaching?

A. Take the medication as needed without a schedule.B. Avoid driving while taking this medication.C. Increase the dose if symptoms persist.D. Discontinue the medication abruptly if feeling better.

Correct Answer: B

Rationale: Benzodiazepines can cause sedation and impaired coordination, making driving unsafe. Taking as needed, increasing doses, or abruptly stopping can lead to misuse, tolerance, or withdrawal, and should be avoided.