A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make?
Succinylcholine is given to reduce muscle movements during therapy.
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
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 reports an inability to breathe easily.
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
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?
Refrains from manipulating others to earn dining room privileges
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.
A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?
Interview the client in a private setting.
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?
Substance use disorder
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
I am able to go to work every day, so I don't have a problem.
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 followi
Ask the family member if they have any thoughts or questions about the treatment plan.
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
Anhedonia
Flat facial expression
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 flings indicating lithium toxicity?
A client who has a sodium level of 128 mEq/L
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?
Hypertension
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.
A client who has a diagnosis of depression 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 nurs
Allow the client time to formulate an answer.
A nurse in an 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 a blood pressure of 210/105 mm Hg and temperature of 39.9
Determine the client's prescribed medication regimen.
A charge nurse is preparing an education session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?
In the event a client threatens harm to others, medications can be administered without consent.
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
A client who is taking lamotrigine and has developed a rash
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?
Avoid looking directly at the light during treatment.
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 of the teaching about the medication?
I should eat a regular diet with normal amounts of salt and fluids.
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.
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 t
Hand tremors
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?
Report the occurrence to the charge nurse.
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
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.
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero i
14 mL
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?
Set realistic limits on the client's behavior.
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 a
Do not administer the lorazepam.
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 there nurse tak
Assess the client for evidence of a perceptual disturbance.
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 manifestation. The nurse should teach the partner to expect which of the following manifestations to occur first?
Frequently misplaces objects
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 th
St. John's wort
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?
Talk with the client about activities they enjoyed with their partner.
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 reports command hallucinations.
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
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?
Orthostatic hypotension
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.
A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?
Remove unnecessary equipment from the child's surroundings.
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'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pat
Clang association
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?
A client was administered one-half of the prescribed dose of medication.
A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomexetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?
Dark urine
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?
Emotional lability
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?
You might experience difficulties with sexual functioning while taking this medication.
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?
I feel so empty without my wife that it's hard to get up every morning.
A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?
A client who has borderline personality disorder threatened to harm their roommate.
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?
Encourage frequent rest periods throughout the day.
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.
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 for suicide?
It is easier to talk about my feelings now.
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?
Aggression toward animals
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?
Inappropriate dress
A nurse 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?
Instruct the client to avoid driving during initial therapy.
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 8.7%
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 refrain from self-mutilation.
A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse?
Provide frequent high-calorie snacks.
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?
Attention to body language
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?
Attending a relapse prevention group several times each week
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.
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?
Anhedonia
A nurse is caring for 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 is not uncommon to feel angry toward yourself or others.
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?
Ask the client what the voices are saying.