NR 326 Week 2 Quiz 1

A. Documentation of all interventions that were tried and response of patient, and the progression of nursing care/interventions, leading up to necessary r/s. B. Documentation of offering fluids, food, comfort/pain assessment, V/S, especially breathing/RR; toileting. C. Time limits for seclusion or restraints = 4 hours for adults; 2 hours 9-17; 1 hour for 8 and under D. Use chemical restraints on all clients with a history of anger and aggression when they exhibit escalating behaviors. 6.A nurse is caring for an adolescent client with a history of violent behavior. The client asked the nurse to keep information confidential about the desire to kill several classmates and a school teacher. Which statement by the nurse is the best response? A. "Because you are a minor, I have to share any information that I feel is important with your parents." B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us." D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me." 7.A nurse on a behavioral health unit is monitoring an adult client who was placed in 4 point restraints. Nursing care for the client in restraint includes which of the following? (SATA) A. Ensure that a face-to-face assessment has been completed by a physician within 1 hour of placing the client in restraint. B. Ensure and document offering fluids and toileting to the client. C. Ensure to maintain the client's dignity and respect. D. Ensure not to remove restraints from the client demonstrating calm behavior without first obtaining a provider order. E. Ensure the patient must be sleeping before restraints can be removed and the client lets the nurse know when they are ready to be free from restraints as this is part of recipient rights. F.Ensure waiting at least 12 hours after restraints are placed, before considering removing restraints. 8. The nurse initiating a therapeutic relationship with clients knows which of the following defense mechanisms are always adaptive and never maladaptive? A. Suppression and Repression B.Altruism and Sublimation C. Undoing and Intellectualization D. Rationalization and Compensation 9.A client tells a nurse that the nurse is the only one who cares about them, yet the following day, the client refuses to talk to that nurse. This is an example of which of the following defense mechanisms? A. Compensation B. Undoing 15.A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive- communication? A. “I wish you would not make me angry.” B. “I feel angry when you leave me.” C. “You’d better listen to me.” D. “It makes me angry when you interrupt me. 16. A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the