A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?Raise the pitch of the voice when speaking to the client Begin the interview by explaining the plan of careInterview the client in a private setting Ask the client to complete a detailed questionnaire
Interview the client in a private setting
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first? Diazepam 5 mg IV bolus Clonidine 0.1 mg transdermal patch Naltrexone 380 mg IMBupropion 150 mg PO
Diazepam 5 mg IV bolus
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lbs. Available is chlorpromazine syrup 10mg/5ml. How many ml should the nurse administer?
14 ml
A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? St. John's wort Saw palmetto EchinaceaGinkgo
St. John's wort
A nurse is caring for a client in a mental facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? Confront the staff memberEncourage the client to report the incidentDocument the incident in the client's health recordReport the occurrence to the charge nurse
Report the occurrence to the charge nurse
A nurse is in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? Advise the client to take frequent sips of water Instruct the client to avoid driving during initial therapyConsult a dietitian for a calorie-controlled diet plan Recommend that the client exercise regularly
Instruct the client to avoid driving during initial therapy
A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? Ensure a family member can be present during treatmentIncrease fluid intake for 24 hour before the treatment startsChange position slowly when the treatment is complete Avoid looking directly at the light during treatment
Avoid looking directly at the light during treatment
A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? "Information regarding clients should remain confidential until after their death" "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states" "As long as the client identity is disguised, their health information can be shared between professionals on the internet" "In the event a client threatens harm to others, medications can be administered without consent
In the event a client threatens harm to others, medications can be administered without consent
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? The client needs excessive external input to make everyday decisions The client demonstrates a dedication to their job that excludes time for leisure activities The client adheres to a rigid set of rules The client has difficulty starting new relationships unless they feel accepted
The client needs excessive external input to make everyday decisions
A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include? Taking the oral medication buprenorphine to prevent alcohol use Attending a relapse prevention group several times each week Beginning a methadone treatment program at a local center Living with their parent, who has promised to keep them away from alcohol
Attending a relapse prevention group several times each week
A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?Inability to recognize family memnbersChooses clothing that is inappropriate for the weatherExhibits a change in personality Frequently misplaces objects
Frequently misplaces objects
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? Call the family member to the side to inquire if they have questions or concerns about the treatment planAdvise the family member that this treatment plan has been developed specifically for the client to follow Ask the family member if they have any thoughts or questions about the treatment plan Document that the family member does not support the medication treatment plan
...
A nurse in a emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and blood pressure of 210/105 mmHg and a temperature of 103/8 F. Which of the following actions should the nurse take first?Administer phentolamine 5 mg IV to the client Apply a hypothermic blanket to the client Determine the client's prescribed medication regimen Initiate IV access for the client
Determine the client's prescribed medication regimen
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? Move the client to a room near the nurses' station Limit visitors until the client is oriented to the environment Tell the client that their partner is deceased Talk with the client about activities they enjoyed with their partner
Talk with the client about activities they enjoyed with their partner
A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? A client who has a fasting blood glucose level of 80 mg/dlA client who has a sodium level of 128 meq/L A client who has a BUN of 18 mg/dLA client who has a potassium level of 3.6 meq/L
A client who has a sodium level of 128 meq/L
A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? Increased confusion Sleep disturbances Cluttered environment Inappropriate dress
Inappropriate dress
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? Total body fat of 8.7% Potassium 3.6 meq/LTemperature 96.9 FHeart rate of 54/min
Total body fat of 8.7%
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? "It will be better for you to keep busy to avoid thinking about your child's death" "You will complete the grieving process about a year after your child's death" "The grief process will start once your child actually dies" "It is not uncommon to feel angry toward yourself or others
It is not uncommon to feel angry toward yourself or others
A nurse in a clinic is assessing a client whose partner died about 4 months ago. Which of the following statement indicates that the client is at risk for complicated grief? "I wish I had been nicer and more generous with my life before she died" "I told my wife to go to the doctor, but she wouldn't listen to me" "I think about my wife all the time when I go on outings with my family" "I feel so empty without my wife that it's hard to get up every morning
I feel so empty without my wife that it's hard to get up every morning
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicated that the client is using denial as a defense mechanism?"I put in extra hours at work so I won't have to think about drinking""I know that wine is good for my heart, so that's why I drink some each evening" "I make up for my drinking by taking my partner on nice vacations" "I am able to go to work every day, so I don't have a problem
I am able to go to work every day, so I don't have a problem
A nurse in a provider's office is collecting a health history from the guardian of a school age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? Reduced appetite Fatigue Dark urine Sweating
Dark urine
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? The client will take prescribed medications as scheduled The client will express feelings of frustration The client will refrain from self mutilation The client will participate in group therapy
The client will refrain from self mutilation
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? A client refuses electroconvulsive therapy after signing the consent form A client who was voluntarily admitted left the unit against medical advice A client was administered one half of the prescribed dose of mediation A client was placed in restraints after attempts to de escalate aggressive behaviors failed
A client was administered one half of the prescribed dose of mediation
A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? Encourage the client to drink 125 ml of fluid each hour while awake Allow the client to eat independently in their room Weigh the client twice weekly Measure the client's vital signs once each day
Encourage the client to drink 125 ml of fluid each hour while awake
A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? Shuffling gait Hypotension Decreased WBC count Blurred vision
Shuffling gait
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? DiarrheaHeavy menstrual bleeding Tachycardia Orthostatic hypotension
Orthostatic hypotension
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? Behave in a friendly manner toward the client Set realistic limits on the client's behavior Show respect for the client's need for isolation Act as a role model assertiveness
Set realistic limits on the client's behavior
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? Promote the use of music to compete with the client's auditory hallucinations Inform the client that the auditory hallucinations Avoid asking the client if they are experiencing auditory hallucinations Instruct the client on the use of voice recognition regarding the auditory hallucinations
Promote the use of music to compete with the client's auditory hallucinations
A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners A client who has depression reports having a lack of interest in assisting their partner in the care of their childrenA client who has borderline personality disorder threatened to harm their roommateA adolescent client who has anorexia nervosa and has a SMI of 17
A client who has borderline personality disorder threatened to harm their roommate
A client who has a diagnosis is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? Allow the client time to formulate an answer Prompt the client to give a response Move on to the next client Offer the client a suggestion for a goal
Allow the client time to formulate an answer
A nurse is caring for a group of clients. Which of the following findings should the nurse report? A client who is taking clozapine and has a WBC count of 7,500 A client who is taking lamotrigine and has developed a rash A client who is taking valproate and has a platelet count of 150,000 A client who is taking lithium and has a lithium level of 1.2 meq/L
A client who is taking lamotrigine and has developed a rash
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?Do not administer the lorazepam Request a prescription for IV lorazepam Request that another nurse attempt to administer the lorazepam Place the lorazepam in the client's food
Do not administer the lorazepam
A nurse is assessing a client who has recently used cocaine. Which of the following findings should the nurse expect? Polyphagia Hypertension Decreased temperature Depressed mood
Hypertension
A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?Arrange one to one observation of the client Encourage interaction with the client's peers Administer mediation for depressive disorder Encourage the client to attend a support group
Arrange one to one observation of the client
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? Male genderHyperthyroidismSubstance use disorder Being married
Substance use disorder
A nurse is planning care for a newly admitted client who has a bipolar disorder and is experiencing mania. Which of the following actions is the priority action by the nurse?Schedule the client for group therapy sessions Maintain consistent rules Provide frequent high calorie snacks Avoid the use of value judgments
Provide frequent high calorie snacks
A nurse is caring for a client who is undergoing electroconvulsive therapy and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? "Succinylcholine will enhance the therapeutic effects of this treatment" "Succinylcholine is given to reduce muscle movements during therapy" "Succinylcholine will decrease the anxiety level that you might experience with this treatment" "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure
Succinylcholine is given to reduce muscle movements during therapy
A nurse is planning care for a 7 yo child who has ADHD. Which of the following interventions should the nurse identify as the priority? Decrease distractions during meal time Provide positive feedback when the child completes a taskClearly identify consequences for unacceptable behavior Remove unnecessary equipment from the child's surroundings
Remove unnecessary equipment from the child's surroundings
During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? The client is interested in what the nurse is saying The client is attempting to manipulate the nurse The client is physically attracted to the nurseThe client needs to feel accepted by the nurse
The client is interested in what the nurse is saying
A nurse is delegating client care tasks to a licensed practical nurse and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? Obtain the weight of a client who has bipolar disorder and is experiencing maniaAssess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 daysMonitor the cardiovascular status of a client who is experiencing serotonin syndrome Change the dressings of a client who has borderline personality disorder and superficial self inflicted wounds
Change the dressings of a client who has borderline personality disorder and superficial self inflicted wounds
A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk of suicide? "I am relieved that my financial affairs are now in order" "It is easier to talk about my feelings now""Suddenly I have enough energy to do anything I want" "Thank you for always taking such good care of me
It is easier to talk about my feelings now
A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding for the teaching about the medication?"I should eat a regular diet with normal amounts of salt and fluids" "I should discontinue the lithium when I begin to feel better" "I need to be careful to avoid becoming addicted to the lithium" "I can skip a dose of the medication if my stomach is upset
I should eat a regular diet with normal amounts of salt and fluids
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? Delusions Neologisms Anhedonia Echopraxia
Anhedonia
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the mediation? Sore throat Photophobia Hand tremors Constipation
Hand tremors
A nurse is assessing a school age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? Feelings of remorseExtended periods of depression Deficits in intellectual functioning Aggression toward animals
Aggression toward animals
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take? Ask the client to identify the bomb in the room Initiate disaster protocols per facility policies and procedures Assess the client for evidence of a perceptual disturbance Convince the client that there is no bomb in their room
Assess the client for evidence of a perceptual disturbance
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I am red, in the head, and I am going to bed!" The nurse should document the client's speech pattern as which of the following? Clang association Word salad Neologism Echolalia
Clang association
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? Gather supplies for endotracheal intubation Administer a beta blocker intravenously Position the client in a low fowler's position Place a cooling blanket over the client
Gather supplies for endotracheal intubation
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?Emotional lability self sacrificing Suspicious of othersGrandiosity
Emotional lability
A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? The client recently lost a grandparent in a motor vehicle crash The client's town was hit by a tornado The client's youngest child is leaving for college The client is ambivalent about their upcoming retirement
The client recently lost a grandparent in a motor vehicle crash
A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? Have the client participate in a morning aerobics group Encourage frequent rest periods throughout the day Provide a distraction such as television at night Offer the client hot chocolate at bedtime
Encourage frequent rest periods throughout the day
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions demonstrates the use of active listening? Offering self Use of silenceAttention to body languageReflection of feelings
Attention to body language
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? The client's chart indicates a 3 lb weight gain in 1 month The client reports an inability to breathe easily The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL The client reports having recently started smoking cigarettes
The client reports an inability to breathe easily
A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply)Feelings of hopelessness Pressured speech Grandiosity Anhedonia Flat facial expression
Feelings of hopelessness Anhedonia Flat facial expression
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should nurse include in the teaching? "You night notice an increase in saliva while taking this medication?" "You might experience difficulties with sexual functioning while taking this medication" "You should expect an improvement in symptoms of depression in 3-4 days" "You may notice a temporary ringing in the ears when starting this medication
You might experience difficulties with sexual functioning while taking this medication
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? The client is exhibiting echolalia The client reports command hallucinations The client reports loss of motication The client is exhibiting blunted affect
The client reports command hallucinations
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? Tell the client that the voices do not really existTouch the client to help reduce feelings of anxiety Instruct the client to go to a quiet room when the voices start talking Ask the client what the voices are saying
Ask the client what the voices are saying
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? "If you do my homework for me, I won't bother you for the rest of the day" "Mom is always upset""It's not the children's fault. Its mine" "Its your fault that were having problems as a family
If you do my homework for me, I won't bother you for the rest of the day
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? Controls anger outbursts to avoid being placed in seclusionNo longer exhibits a fear of social or public situations Refrains from manipulating others to earn dining room privilegesImitates the therapist's use of a relaxation technique
Refrains from manipulating others to earn dining room privileges
A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? Respite care Partial hospitalization Adult day care program Geropsychiatric unit
Respite care
A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? An adolescent family member who questions parental authority A family with 3 generations in the same household Older children who are responsible for their younger siblings 2 adults and their children from prior relationships in the same household
Older children who are responsible for their younger siblings
A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? Inform the client that this admission is confidential Introduce the client to other clients in the day room Assist the client in facilitating a behavioral change Determine coping strategies that the client has used in the past
Inform the client that this admission is confidential
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? Slow onsetAphasiaConfabulation Easily distracted
Easily distracted
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? Offer the client various choices for meal selectionAssign different nursing personnel for each shift Permit the client to perform daily rituals to decrease anxiety Maintain an environment that has low lighting
Permit the client to perform daily rituals to decrease anxiety
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? Encourage the client to participate in group therapyInstruct the client to avoid napping during the day Offer the client high calorie finger foods frequently Decrease the client's daily fiber intake
Offer the client high calorie finger foods frequently
A nurse is teaching a partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? Obsessive attention to detail Inability to sleep Reports of fatigue Isolation from others
Inability to sleep
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? Orient the client to person, place, and timeAssist the client with deep breathing exercises Calm the client by using therapeutic touch Have the client sit alone in a quiet room
Assist the client with deep breathing exercises
A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? Encourage the parents to avoid discussing the death with their other children to protect their feelingsRecommend each parent grieve in private to avoid hindering each other's healing Suggest forming a weekly support group for parents who have experienced the death of a child Advise the parents to begin counseling if they are still grieving in a few months
Suggest forming a weekly support group for parents who have experienced the death of a child
A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? Complete documentation about the client's status every hour while they are in restraints Maintain the client in restraints for a minimum of 4 hour Apply restraints when other means of managing the client's behavior have failed Request that the provider assess the client within 8 hr of the application time
Apply restraints when other means of managing the client's behavior have failed
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Sedation RhinorrheaBradycardia Hypothermia
Rhinorrhea
A nurse is facilitating a community meeting for acute care for clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? Tell the client to talk less or risk being removed from the meeting Ask group members to discuss their feelings about this client's monopolizing behaviorEnd the group meeting and take the client aside to discuss the disruptive behavior Focus on other group members and ignore the client who is doing all the talking
Ask group members to discuss their feelings about this client's monopolizing behavior
A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? Amenorrhea Lanugo Cold extremities Tooth erosion
Tooth erosion
A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (select all that apply) Occupational therapyMeal delivery servicesSpeech language pathologist Physical therapy Home health services
Occupational therapyMeal delivery servicesPhysical therapy Home health services
A nurse in a community health center is working with a group of clients who have post traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? Response prevention Guided imagery Aversion therapy Light therapy
Guided imagery
A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? Use a screening tool to evaluate the client for depressionAsk the provider to decrease the dosage of the client's blood pressure medication Instruct the client to decrease intake of vitamin B12Suggest the client go for a brisk walk 20 min just before bedtime
Use a screening tool to evaluate the client for depression
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team? Calling family membersSpending time alone Giving away possessions Excessive crying
Giving away possessions
A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? The client is married The client recently received a promotion at work The client has COPDThe client is a male
The client has COPD
A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? Nonmaleficence Veracity Justice Autonomy
Nonmaleficence
A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and fear of gaining weight. The client states, "I am so fat I cant even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat.""You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight.""You don't want to look at yourself because you think you are fat.""You and I can work together to overcome your fears of gaining weight.
You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight.
A nurse in a community health center is teaching families of clients who have post traumatic stress disorder about expected clinical manifestations. Which of the following manifestations should the nurse include? Repeatedly talks about the traumatic incident Sleeps excessively Experiences feelings of isolation Uses repetitive speech
Experiences feelings of isolation
A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? "I am going to order a wheelchair for when I'm unable to walk.""I am going to stop paying my bills since I won't be around much longer.""I wish you would go take care of somebody who actually needs you.""I am sure I'm going to be able to continue to care for myself without help.
I am going to order a wheelchair for when I'm unable to walk.
A nurse is caring for 4 clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? A 17 year old client who lives with friendsA 50 year old client who has a blood alcohol level of 80 A 35 year old client who has major depressive disorder A 65 year old client who just received a dose of morphine
A 35 year old client who has major depressive disorder
A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? Provide teaching about the use of positive coping mechanisms Establish screening programs to identify at risk clients Refer survivors of intimate partner abuse to a legal advocacy program Organize rehabilitation therapy for clients who have experienced intimate partner abuse
Establish screening programs to identify at risk clients
A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following OTC medications that the client reports taking should alert the nurse to a potential adverse reaction? Lansoprazole Naproxen Magnesium hydroxide Phenylephrine
Phenylephrine
A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that what which of the following treatment options can offer interdisciplinary services for the client at home? Community mental health centerMental health day program Partial hospitalization program Assertive community treatment
Assertive community treatment
A nurse is preparing to administer diazepam 7.5 mg IV bolus to client for alcohol withdrawal. Available is diazepam injection 5 mg/ml. How many ml should the nurse administer?
1.5 ml
A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? "It appears as though you would like to open the door""You will feel more comfortable after you've been here for a while""It is okay to not want to be here" "You really shouldn't be pushing on the door
It appears as though you would like to open the door
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? Fear of abandonment Motor and verbal ticsHostile behavior Language delay
Language delay
A nurse is assessing a client who has major depressive disorder and has been receiving amitripyline for 1 week. Which of the following outcomes should the nurse expect? Rapid improvement in affect within 30-60 min after taking the mediation Greater risk of attempting suicide as affect and energy improve Onset of frequent, loose stools Development of physiologic dependence on the medication
Greater risk of attempting suicide as affect and energy improve
A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I will use the same plan of care and interventions for each client who has depression.""Each nurse will develop a separate plan of care for each client who has depression.""I will update the plan of care as a client's manifestations of depression change.""An assistive personnel can use the plan of care for client teaching.
I will update the plan of care as a client's manifestations of depression change.
A nurse in an emergency department is caring for a female adolescent who has diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? "She works so hard at ballet. Will she still be able to perform?""She won't let me take the trash from her room. I'm concerned about what she has in there.""She told me she was tired, so I did her chores for her today.""She is happier with her appearance now that she's lost some weight.
She won't let me take the trash from her room. I'm concerned about what she has in there.
A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? "I will spend extra time at work to keep from feeling depressed.""I will talk about my feelings with a close friend.""I will be able to learn how to prevent my partner's attacks.""I will use meditation instead of taking my antidepressant.
I will talk about my feelings with a close friend.
A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include? Additional acute episodes of depression are unlikely following inpatient careEarly identification of changes, such as decreased social involvement, is important Medication compliance will prevent further need for inpatient hospitalization It is helpful to regularly reinforce to the client that things will get better
Early identification of changes, such as decreased social involvement, is important
A nurse in a mental health clinic is caring for a client who has PTSD after returning from military deployment. Which of the following is this priority action for the nurse to take? Assist the client to identify personal area of strength Encourage the client to talk about experiences during the deployment Stay with the client when flashbacks occur Teach the client stress management techniques
Stay with the client when flashbacks occur
A nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include should the nurse include in the teaching? The program will help the client accept the responsibility for the disorderThe client should obtain a sponsor before discharge for an increased chance of recovery The client will need to identify individuals who have contributed to the disorderThe program will need a prescription from the client's provider prior to attendance
The client should obtain a sponsor before discharge for an increased chance of recovery
A nurse is updating the plan of care who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? Include a liquid supplement with meals Identify the client's trigger foods Allow the client at least for each meal Weigh the client at bedtime each day
Identify the client's trigger foods
A nurse in the emergency department is caring for 4 clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A school aged child who has bruises on the kneesAn older adult client who is bedbound and has a stage IV pressure ulcerAn adolescent who has vaginal candida infection A young adult who is pregnant and has a sprained ankle
An older adult client who is bedbound and has a stage IV pressure ulcer
A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? Weight gain Tinnitus TachycardiaIncreased salivation
Tachycardia
A nurse is reviewing the laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? WBC count 2,5000Hgb 11.5 Platelets 150,000RBC count 3.5 million
WBC count 2,5000
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? "Why do you think you deserve this punishment?"Don't worry about being punished by God.""Let's talk about what is upsetting you.""You shouldn't say things that will upset you so much.
Let's talk about what is upsetting you.
A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? "I will avoid social events until my partner has completed treatment.""It is important for me to focus my attention on my partner's addiction.""I will not take charge of my partner's work responsibilities.""I want my partner to promise to change addictive behaviors.
I will not take charge of my partner's work responsibilities.
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? Panic Moderate Mild Severe
Mild
A nurse in a mental health clinic is planning care for 4 clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Discuss outpatient resources with a client who has post-traumatic stress disorder.Create a plan of care for a client who is experiencing alcohol withdrawal.Explain sleep hygiene to a client who has insomnia.Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? Administer phenytoin 30 min prior to the procedure.Instruct the client to expect a headache following the procedure.Place the client in four point restraints prior to the procedure.Monitor the client's cardiac rhythm during the procedure.
Monitor the client's cardiac rhythm during the procedure.
A nurse on an acute mental health facility is receiving change of shift report for 4 clients. Which of the following clients should the nurse assess first? A client who does not recognize familiar peopleA client who cannot verbalize their needsA client who is awake and disoriented at nightA client who is experiencing delusions of persecution
A client who is experiencing delusions of persecution
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? Increased creatine phosphokinase (CPK)Increased low-density lipoproteins (LDL)Decreased fasting blood glucoseDecreased aspartate aminotransferase (AST)
Increased creatine phosphokinase (CPK)
A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? Call the provider to obtain an immediate prescription for restraintsPrepare to administer benzodiazepine IMCall for a team of staff members to help wit the situationCheck the client who was hit for injuries
Call for a team of staff members to help wit the situation
A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? Document the client's behavior every 8 hr.Limit the client's fluid intake to 50 mL/hr.Renew the prescription for the client every 4 hr.Toilet the client every 4 hr.
Renew the prescription for the client every 4 hr.
A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self directed injury or injuring others?Inability to communicate with othersFeelings of absence of self-worthLack of motivation to perform daily tasksCommand hallucinations
Command hallucinations
A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? "Clients can't refuse to take medications if they are admitted involuntarily.""You can notify a client's family if they are admitted involuntarily.""Clients who are admitted involuntarily maintain the right to give informed consent for procedures.""You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions.
Clients who are admitted involuntarily maintain the right to give informed consent for procedures.
A nurse is caring for a child who has conduct disorder and is behaving in an destructive manner, throwing object, and kicking others. Which of the following therapeutic nursing interventions is the priority? Encourage expression of feelings Support the child's attendance at an assertiveness training group Assist the child to perform relaxation breathing Reduce environmental stimuli
...
A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? "This disease will increase our child's risk for high blood pressure.""It is important for our child to have regular dental checkups.""We need to weigh our child daily for several weeks, then once per week.""Bleeding during our child's periods will increase because of this disease.
It is important for our child to have regular dental checkups.
A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? Blurred visionOrthostatic hypotensionDry mouthAcute dystonia
Acute dystonia
A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours a go following a MVC. The client's admission blood alcohol level was 325 mg/dl. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?SomnolenceBlood pressure 154/96 mm HgPinpoint pupilsBlood glucose 210 mg/dL
Blood pressure 154/96 mm Hg
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? Move the client who has bipolar disorder to a private roomAdminister sleep medication to the client who has bipolar disorder.Move the client who has severe depression to a private room.Administer sleep medication to the client who has severe depression.
Move the client who has bipolar disorder to a private room
A nurse is receiving change of shift report for 4 clients. Which of the following clients should the nurse plan to see first? A client who has avoidant personality disorder and refuses to attend group therapyA client who has bipolar disorder and reports being kidnapped by aliens overnightA client who is taking bupropion and reports having insomnia the past 2 nightsA client who is taking clozapine and reports a sore throat and chills
A client who is taking clozapine and reports a sore throat and chills
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? Develop a code word that means "time to go."Identify signs of escalation of violence.Have a predetermined place to go in the event of violence.Keep a hidden packed bag of necessities.
Identify signs of escalation of violence.
A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? Allowing a client to choose which unit activities to attendAttempting alternative therapies instead of restraints for a client who is combativeProviding a client with accurate information about their prognosisSpending adequate time with a client who is verbally abusive
Spending adequate time with a client who is verbally abusive
A school nurse is assessing a child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing PTSD? Clinging behaviors directed toward a teacherIncreased time spent sleepingIntense focus on school workLack of interest in an upcoming holiday
Lack of interest in an upcoming holiday
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? "You probably want to hold your baby.""I'll stay with you just in case you want to talk.""I know how you must be feeling.""It hurts now, but things will be better soon.
I'll stay with you just in case you want to talk.