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A nurse is assessing a client who has schizophrenia. Which of the...

  1. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? SATA
  • Delusion of grandeur
  • Decreased motivation
  • Auditory hallucinations
  • Flight of ideas
  • Impaired memory

 

  1. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates an accurate understanding of this medication's effects?
  • I know that I will be able to think more clearly now
  • I'll take my medicine at bedtime because it will make me drowsy
  • I need to tell my doctor if I start gaining weight
  • This medicine will help me relax and feel less anxious

 

  1. A nurse is caring for a client who had borderline personality disorder. Which of the following actions should the nurse take?
  • Encourage the use of countertransference for the client
  • Demonstrate a sympathetic attitude toward the client when providing care
  • Maintain consistency in assignment health care for the client
  • Provide consistent boundaries for the client - Sheryl doesn't like answer

 

  1. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client refusal of medications?
  • Beneficence
  • Veracity
  • Autonomy
  • Justice

 

 

  1. A nurse is caring for a client who has schizophrenia. The clients call to discuss the client condition. Which of the following is the appropriate nursing action?
  • Contact the provider
  • Contact the facility legal department
  • Consult the client family
  • Consult the client

 

  1. A nurse is caring for a client in the emergency department who states that the client was beaten and sexual assaulted by her partner. After a rapid assessment. Which of the following actions should the nurse plan to take next?
  • Offer prophylactic medication to prevent STIs
  • Provide a trained advocate to stay with the client
  • Request a mental consultation for the client
  • Conduct a pregnancy test

 

  1. A nurse is caring for a client who is involuntary admitted for major depressive disorder ad refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?
  • Administer the medication to the client via IM injection
  • Implement consequences until client takes the medication
  • Offer the client the medication at the scheduled does time
  • Inform the client that he does not have the right to refuse the medication

 

  1. A nurse is assessing client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during the situational crisis?
  • What do you do to cope with the problem in your life?
  • Who do you talk to when you need help?
  • How do you think event is affecting your life?
  • Are you having thoughts of harming yourself?

 

 

  1. A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan?
  • Teach the client to practice systematic desensitization
  • Refer to the client to self help group
  • Contact the close relative of the client to discuss the discharge plan
  • Request a discharge prescription for buprenorphine for the client

 

  1. A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following should the nurse take?
  • Have the provider assess the client within 1 hr after applying restraint
  • Request that the provider renew the prescription for restraints every 8 hr
  • Evaluate the client hourly which the restraints are applied
  • Obtain a prescription for restraints on am as needed basis

 

  1. A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medication is contraindicated when taken with selegiline?
  • Warfarin
  • Fluoxetine
  • Acetaminophen
  • Calcium carbonate

 

  1. A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states "I feel unmotivated and don't feel like leaving my home". Which of the following recommendations should the nurse make to address the client social isolation?
  • Practice guided imagery each morning
  • Join a low impact exercise class
  • Write journal daily
  • Enroll in a online self help course

 

  1. A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
  • A client who states she did not get a promotion because her boss dislikes her
  • A client who states she will worry about her grades after she finishes planning a party
  • A client who has a stomach pain before presenting a project to his coworker
  • A client who partners died 5 years ago still talk about him in the preset tense

 

  1. A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?
  • Encourage the client to describe his feelings in a journal
  • Administer a dose of atomoxetine to the client
  • Encourage the client to watch the tv as a distraction
  • Administer a dose of alprazolam to the client

 

  1. A nurse is making room assignment for new admissions. Which of the following client should the nurse place closest to the nurse's station?
  • A client who has moderate stage Alzheimer's disease
  • A client who has a history of dependent personality disorder
  • A client who has schizotypal personality disorder
  • A client who has history of alcohol use disorder

 

  1. A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
  • Encourage the client to participate in group therapy
  • Establish rapport to foster trust
  • Implement continuous one-to-one observation.
  • Ask the client to sign a non-suicide contract

 

  1. A nurse is caring for a client who was involuntary committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
  • Tell the client he cannot refuse the treatment because he was involuntarily committed
  • Document the cline refusal of the treatment in the medical record
  • Inform the client the ECT does not require consent
  • Ask the client gamily to encourage the client to receive ECT

 

  1. A nurse in a long-term care facility us caring for a client. The nurse should identify that which of the following conditions places the clint at an increased risk for developing delirium?
  • WBC count 13,000/mm
  • BUN 16 mg/dL
  • Hypertension
  • Neuropathy

 

  1. A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?
  • Request that the client's guardian sign of consent.
  • Explain implied consent to the client's family.
  • Contact the facility social worker to obtain consent.
  • Ask the charge nurse to obtain informed consent.

 

  1. A nurse is caring for a client who has a personality disorder and is using transference to cope. Which if the following behaviors should the nurse expect?
  • Talking negatively about other staff members
  • Expressing frustration regarding unit rules
  • Reacting to the nurse as though she were his mother
  • Refusing to participate in group activities

 

  1. A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?
  • Intake
  • Edema
  • Heart rhythm
  • Temperature

 

  1. A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?
  • Ask the client about a recent change in laundry detergents
  • Withhold the next of the medication
  • Explain that the medication causes a temporary rash
  • Apply hydrocortisone cream on the client rash

 

  1. A nurse is caring for a client who has been talking valproic acid, which of the following is an expected outcome of the medication?
  • The client has decreased euphoric mood
  • The client reports improved short term hallucinations
  • The client has decreased anxiety

 

  1. A nurse has placed a client who has become physically aggressive into seclusion. Which of the following action should the nurse take?
  • Monitor the client vital signs every 4 hr
  • Offer the client food every 2 hr
  • Obtained the provider prescription within 60 mins
  • Document the client behavior every 15 min.

 

  1. A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
  • The client manifestations developed suddenly
  • The client is unable to recognize objects
  • The client speech is slow and repetitious
  • The client has a flat affect

 

  1. A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider? ---- platelets 100,000/mm3

            -WBC count 8,000/mm3

            - RBC count 4.9 million/mm3 

            - hemoglobin 16 g/dL 

  1. A home health nurse visits a client who lost their partner 2 years ago. Which of the following by the client indicates a maladaptive grief response?
  • The client gives away some of the partner belongings
  • The client is unable to perform basic hygiene tasks
  • The client expresses feelings of guilt
  • The client relocates from a house to an apartment

 

  1. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client personal coping skills?
  • Can you describe how you are currently feeling?
  • Do you see your current situation affecting your future?
  • How does this situation affect your life?
  • How have you dealt with similar situation in the past?

 

  1. A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first ?
  • As staff members to describe their most traumatic memories of the event
  • Have staff members discuss their involvement in the event
  • Reassure staff members that the debriefing is confidential
  • Provide stress management exercises to the staff members

 

  1. A nurse is assessing a client who has delirium. Which of the following requires immediate interventions by the nurse?
  • Rapid mood swings
  • Command hallucinations
  • Inappropriate speech patterns
  • Impaired memory

 

  1. A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?
  • Dual diagnosis treatment group
  • Dialectical behavior treatment group
  • Desensitization therapy
  • Co-dependents supports group

 

  1. A nurse is caring for a client who has anorexia nervosa. Which if the following findings requires immediate intervention by the nurse?
  • Lanugo covering the body
  • +2 edema of the lower extremities
  • Blood pH 7.60
  • BUN 21 mg/dL
  •  
  1. A nurse is creating a plan of care for a client who has a major depressive disorder. Which of the following interventions should the nurse include in the plan?
  • Keep a bright light on in the client's room at night.
  • Discourage the client from expressing feelings of anger.
  • Identify and schedule alternative group activities for the client.
  • Encourage physical activity for the client during the day.

 

  1. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to assistive personnel?
  • Witness the client's signature on the consent for the procedure.
  • Check the client's condition after the procedure
  • Give the client atropine 30 min before the procedure.
  • Assist the client to ambulate for the first time following the procedure.

 

  1. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
  • Compensation
  • Displacement
  • Denial
  • Rationalization

 

  1. A nurse is caring for a client who has Alzheimer disease. Which of the following findings should the nurse expect?
  • Excessive motor activity
  • Rapid mod swing
  • Failure to recognized familiar objects
  • Altered level of consciousness

 

  1. A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
  • "The client asked me to go on a date with him, but I refused."
  • "The client needs to accept responsibility for his substance use."
  • "The client generally shares his feelings during group therapy sessions."
  • "The client is just like my brother who finally overcame his habit."

 

  1. A nurse in a mental health facility is reviewing the laboratory results of a client who is talking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity?
  • Sodium 132 mEq/L
  • Aspartate aminotransferase 40 units/L
  • Calcium 10.0 mg/dL
  • WBC 6,000/mm3
  •  
  1. A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which if the following findings indicates the client's adherence to the treatment plan?
  • The client states that she knows she cant be perfect
  • The client current BMI is 14
  • The client's potassium is 3.4 mEq/L
  • The client reports following various cooking blogs

 

  1. A nurse is assessing a client who has a history of substance use disorder and states. "People are out to get me" The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
  • Alcohol
  • Opium
  • Cocaine
  • Heroin

 

  1. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse see first
  • A client who has bipolar and is speaking loudly
  • A client who is taking clozapine and reports a sore throat
  • A client who is taking lithium and reports weight gain
  • A client who has schizophrenia and is experiencing olfactory hallucinations

 

  1. A nurse us teaching a newly nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamic should the nurse include in the teaching?
  • The client has several siblings
  • The client is the oldest of their siblings
  • The client mother has asthma
  • The client father lives in the client's home
  •  
  1. A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
  • Stop the newly licensed nurse from administering the medication.
  • Demonstrate how to verbally de-escalate the situation
  • Assess the need for physical restraints.
  • Discuss the purpose of the medication with the client.

 

  1. A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
  • Plan a menu with the client
  • Offer snacks when the client is hungry
  • Weigh the client every other day
  • Remain with the client for 1 hour after meals.

 

  1. A nurse is caring for a school age child who has a new diagnosis of attention deficit hyperactivity disorder. The nurse should anticipate a prescription from which of the following medications?
  • Risperidone
  • Valproate
  • Lithium
  • Methylphenidate

 

  1. A nurse us conducting an admission interview with a new client who tells the nurse. " my life is so stressful. I can't take it anymore". Which of the following responses should the nurse make first?
  • How have you dealt with stress in the past?
  • Are you thinking of harming yourself?
  • Tell me what makes you feel stressed
  • Let's talk more about what you are experiencing

 

  1. A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? SATA
  • Lanugo
  • Diarrhea
  • Hypotension
  • Bradycardia
  • Russell's sign

 

  1. A nurse is leading a grief group for bereaved clients. Which of the following clients' statements should the nurse report to the provider as an indication of the clinical depression?
  • It'll be a long time before I'm happy again
  • I feel like I'm angry at the whole world right now
  • I don't feel anything but numbness anymore
  • I don't know how I could cope if I don't have my family support

 

  1. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?
  • Hypothyroidism
  • Hepatitis B infection
  • Knee arthroplasty 1 month ago
  • Recent head injury

 

  1. A nurse is providing counselling for a family that consists of two parents and their two adolescents' children. Which of the following family members should the nurse identify as actng in the role of monopolize?
  • The adolescent son who refuses to shar personal feelings
  • The adolescent daughter who attempts to dominate the discussion
  • The mother who expresses honestly toward her space
  • The father who intervenes whenever the siblings argue

 

  1. A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?
  • Social worker
  • Clinical nurse specialist
  • Occupational therapist
  • Recreational therapist

 

  1. A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

- Inform the client that they have the legal right to refuse treatment at any time.

-  Obtain consent from the client's family member 

- Encourage the client to have the procedure.

-  Request another nurse to review the procedure with the client.

 

  1. A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following finding obtained during the initial assessment is the priority to report to other disciplines?
  • Markedly neglected hygiene
  • Poor problem-solving skills
  • Significant weight loss
  • Psychomotor retardation

 

  1. A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?
  • The client says he feels guilty about not spending more time with his partner
  • The client frequently recalls negative experiences that occurred during his marriage
  • The client state that he is unable to eat more then once a day
  • The client relates that he is angry that the provider did not save his partner life.
  1. A nurse is providing teaching to a client who is prescribes methylphenidate for ADHD. Which of the following statements by the client indicates an accurate understanding of this medication's effects?
  • I know that I will be able to think more clearly now
  • I'll take my medicine at bedtime because it will make me drowsy
  • I need to tell my doctor if I start gaining weight
  • This medicine will help me relax and feel less anxious

 

  1. A nurse is caring for a client who has personality disorder. Which of the following actions should the nurse take?
  • Encourage the use of countertransference for the client
  • Demonstrate a sympathetic attitude toward the client when providing care
  • Maintain consistency in assigning health care staff for the client
  • Provide consistent boundaries for the client

 

  1. A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?
  • Asthma
  • Seizure disorder
  • Crohn's disease
  • Hypothyroidism

 

  1. A nurse us caring for a school age child who has conduct disorder and required wrist restraints. Which of the following actions should the nurse take?
  • Obtain a prescription for the restraint within 2 hr pf initiating them
  • Have the child perform range of motion exercise every 3 hr
  • Monitor the child's vital signs every 15 minutes
  • Ensure three fingers will fit between the child's wrist and the restraints

 

  1. A nurse us caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take?
  • Initiate facility procedure for emergency commitment
  • Request a prescription for varenicline from the client's provider
  • Inform the client about polices for dispensing methadone
  • Assess the client using the CAGE questionnaire

 

  1. A nurse is teaching about deep-breathing exercises with a client who reports experiencing intense stress at work. Which of the following statements by the client indicates an understanding of the teaching?
  • I will focus on the causes of my stress during the exercise
  • I will focus on how the muscles in my stomach feel with each breath
  • I will inhale through mu mouth and exhale through my nose

 

  1. A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following finding is the priority to report to the provider?
  • Nausea
  • Heart rate 104/min
  • Random blood glucose 130 mg/dL
  • Sore throat

 

  1. A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?
  • Allow the client unlimited time for the grieving process
  • Discourage the client from forming new relationships
  • Charge the subject when the client becomes upset
  • Offer the client advise about various treatment choices
  •  
  1. A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?
  • Hyperthermia ?
  • Hyperglycemia
  • Decreased heart rate
  • Decreased bp
  •  
  1. A nurse us planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include In the plan?
  • Decrease the client daily intake of fiber
  • Negotiate with the client how much weight she should each week
  • Notify the client about designated times for meals
  • Weigh the client weekly for the first month

 

  1. A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
  • Bowel sounds
  • Oxygen saturation
  • Blood pressure
  • Pupil response

 

  1. A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
  • Ask the client if he intends to harm others
  • Assist the client to explore a list of things that makes him angry
  • Suggest the client make a list of things that makes him angry
  • Role model healthy ways to express anger

 

  1. A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?
  • Encourage the use of problem-solving skills
  • Manage conflict within the group
  • Establish a rapport with group members
  • Maintain the group's focus on identifies issues

 

  1. A nurse is providing behavioral therapy for a client who has obsessive - compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping techniques?
  • Ask a family member to check the lock for you at night
  • Snap a rubber band on your wrist when you think about checking the locks
  • Focus on abdominal breathing whenever you go to check the locks
  • Keep a journal of how often you check the locks each night

 

 

 

 

 

 

 

 

 

 

 

 

 

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