1.

A female client with the diagnosis of mania emerges from her room topless while making
sexual remarks and lewd gestures toward the staff and her peers. Which action would the
nurse take first?
a. Quietly approach the client and escort her to her room to get dressed.
b. Confront the client on the inappropriateness of her behavior and offer her a time out.
c. Ask the other clients to ignore her behavior; eventually she will return to her own
room.
d. Approach the client in the hallway and insist that she go to her own room immediately.

2. The spouse of a client who is scheduled for the insertion of an implantable cardioverter
defibrillator (ICD) expresses anxiety about what would happen if the device discharges
during physical contact. Which information is most appropriate for the nurse to provide to
the spouse?
a. Physical contact should be avoided whenever possible.
b. The spouse would not feel or be harmed by the countershock.
c. The shock would be felt, but it would not cause the spouse any harm.
d. A warning device sounds before countershock, so there is time to move away.

3. A client who is scheduled for permanent transvenous pacemaker insertion states to the
nurse, “I know I need it, but I’m not sure this surgery is a great idea.” Which nursing
response would best help the nurse assess the client’s preoperative concerns?
a. “How does your family feel about the surgery?”
b. “Has anyone taught you about the procedure yet?”
c. “You sound extremely worried. Has anyone told you that the technology is really quite
safe?”
d. You sound uncertain about the procedure. Can you tell me more about what has you
concerned?”

4. A client with superficial varicose veins states to the nurse, “I hate these things. They’re so
ugly. I wish I could get them to go away.” Which therapeutic response would be most
appropriate for the nurse to make to the client?
a. “You should try sclerotherapy. It’s great.”
b. “What makes you so upset about having ugly varicose veins?”
c. “What have you been told about varicose veins and their management?”
d. “I understand how you feel, but you know, they really don’t look all that bad.”

5. A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will
be required. The client becomes angry and states, “I’ll never be the same now.” Based on
this information, which would the nurse identify as the client’s primary concern?
a. Anxiety about the hemodialysis
b. Inability to think clearly because of the treatments needed
c. Potential for noncompliance because of concerns about the disease
d. Altered body image because of the physical changes that may occur

6. A client with the diagnosis of hyperparathyroidism states to the nurse, “I can’t stay on this
diet. It is too difficult for me.” Which therapeutic response by the nurse is best when
intervening in this situation?
a. “Why do you think you find this diet plan difficult to adhere to?”
b. “It really isn’t difficult to stick to this diet. Just avoid milk products.”
c. “You are having a difficult time staying on this plan. Let’s discuss this.”
d. “It is very important that you stay on this diet to avoid forming renal calculi.”

7. A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive
days in the emergency department with hyperglycemia. During the assessment, the client
states to the nurse, “I’m sorry to keep bothering you every day, but I just can’t give
myself those awful shots.” Which therapeutic comment is most appropriate for the nurse
to respond?
a. “I couldn’t give myself a shot either.”
b. “You must learn to give yourself the shots.”
c. “Let me see if we can change your medication.”
d. “Have you had instructions on injecting yourself?”

8. A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive
days in the emergency department with hyperglycemia. During the assessment, the client
 states to the nurse, “I’m sorry to keep bothering you every day, but I just can’t give
myself those awful shots.” Which therapeutic comment is most appropriate for the nurse
to respond?
a. “I couldn’t give myself a shot either.”
b. “You must learn to give yourself the shots.”
c. “Let me see if we can change your medication.”
d. “Have you had instructions on injecting yourself?”

9. The spouse of a dying client states to the nurse, “I don’t think I can come anymore and
watch her die. It’s chewing me up too much!” Which is the most therapeutic response the
nurse would make to the spouse?
a. “It’s hard to watch someone you love die. You’ve been here with your wife every day.
Are you taking any time for yourself?”
b. “Focus on your wife’s pain rather than yours. I know it’s hard, but this isn’t about
what’s happening to you, you know.”
c. “I know it’s hard for you, but she would know if you’re not there, and you would feel so
very guilty all of the rest of your days.”
d. “I think you’re making the right decision. Your wife knows you love her. You don’t have
to come every day. I’ll take care of her.”

10.When the home care nurse arrives, the client with a diagnosis of emphysema is smoking.
Which statement by the nurse would be most therapeutic?
a. “Well, I can see you never got to the stop smoking clinic.”
b. “Now that your secret is out, may we decide what you are going to do?”
c. “Did you explore the stop smoking program at the senior citizens center?”
d. “I wonder if you realize that by smoking you are slowly killing yourself.”

11.A client is to have arterial blood gases drawn. While the nurse is performing Allen’s test,
the client states to the nurse, “What are you doing? No one else has done that!” Which
response to the client is most therapeutic?
a. “I assure you that I am doing the correct procedure. I cannot account for what others
do.”
b. “This step is crucial to safe blood withdrawal. I would not let anyone take my blood
until they did this.”
c. “Oh? You have questions about this? You should insist that they all do this procedure
before drawing up your blood.”
d. “This is a routine precautionary step that simply makes certain your circulation is intact
before a blood sample is obtained.”

12.The nurse is caring for a client who is recovering from an episode of autonomic
hyperreflexia. Which statement would the nurse make to the client to most encourage
therapeutic communication?
a. “How could your home care nurse let this happen?”
b. “Now that this problem is taken care of, I’m sure you’ll be fine.”
c. “I have some time if you would like to talk about what happened to you.”
d. “I’m sure you now understand the importance of preventing this from occurring.”

13.While assisting with bathing, the client who has sustained a spinal cord injury states, “I
can’t do this. I wish I were dead.” Which therapeutic response would the nurse make to
encourage communication?
a. “Why do you say that?”
b. “You wish you were dead?”
c. “Would you prefer a shower instead?”
d. “Are you frustrated with your limitations?”

14.Family members of a client who attempted suicide are tearful. Which statement by the
nurse would be most helpful in the management of their concerns?
a. “I’ll check on when you will be able to see your loved one.”
b. “Believe me when I say that everything possible is being done.”
c. “Don’t worry. You have absolutely nothing to feel guilty about.”
d. “I certainly can see that you are terribly worried about your loved one.”

15.The nurse is caring for an 11-year-old child who has been physically abused. Which
therapeutic action would the nurse include in the plan of care?
 a. Encouraging the child to confront the abuser
b. Providing a care environment that fosters trust
c. Teaching the child to make wise choices when faced with possible abuse
d. Reinforcing for the child that not all adults are capable of abusing children

16.The nurse is caring for a dying client who states, “Will you be the executor of my will?”
How would the nurse best respond to this client?
a. “I must decline your offer because I am your nurse.”
b. “I will carry out your will according to your wishes.”
c. “It is an honor to be named the executor of your will.”
d. “Tell me more so that I can understand your thinking.”

17.A client experiencing urticaria (hives) and pruritus states to the nurse, “What am I going
to do? I’m getting married next week, and I’ll probably be covered in this rash and itching
like crazy.” Which statement made by the nurse is the most therapeutic?
a. “You’re troubled that this will extend into your wedding?”
b. “It’s probably just due to prewedding jitters. You’ll be fine.”
c. “The antihistamine will help a great deal, just you wait and see.”
d. “Do you think this would really be something that could ruin your wedding?”

18.Which statement made by a client who has experienced a spinal cord injury resulting in
chronic immobility issues warrants immediate follow-up by the nurse to assure client
safety?
a. “I’m so angry that this happened to me.”
b. “I really don’t want to live my life like this.”
c. “I’m definitely not looking forward to going home.”
d. “I don’t know if I can make all these major adjustments to my life.”

19.While assessing a 14-year-old child, the nurse notes bruises and cigarette burns on the
child’s chest and rope burns on the buttocks. The child states, “I’m afraid to go home
because my stepfather will be angry with me for telling on him!” The nurse would make
which therapeutic response to the child?
a. “You can’t go back there with that man. How do you think your mother will react?”
b. “You must know that your presence in the house will only irritate your stepfather
more.”
c. “I am sorry that this has happened to you, but you will be safe here until plans can be
made.”
d. “Let’s keep this between you, me, and the primary health care provider until we
formulate further plans to assist you.”

20.The nurse is assessing a client’s suicide potential. Which question is most important for
the nurse to ask the client?
a. “Why do you want to hurt yourself?”
b. “Do you have a plan to hurt yourself?”
c. “Has anyone in your family committed suicide?”
d. “Can you describe how you are feeling right now?”