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53. A nurse on a mental health unit placed a client in mechanical

restraints after the client assaulted another client. Which of the following actions should the nurse take?
A.   Request that the provider renew the prescription for restraints every 8 hr.
B.   Evaluate the client hourly while the restraints are applied.
C.    Obtain a prescription for restraints on as - needed basis.
D.   Have the provide assess the client within 1 hr after applying the restraints.
 
 
54. 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's social isolation?
A.   Write in a journal daily
B.   Practice guided imagery each morning
C.    Join a low - impact exercise class
D.   Enroll in an online self-therapy course
 
 
 
55. A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol disorder. Which of the following recommendations should the nurse include in the plan?
A.   Refer the client to a self - help group
B.    Teach the client to practice systematic desensitization
C.    Contact a close relative of the client to discuss the discharge plan
D.   Request a discharge prescription for buprenorphine for the client.
 
 
56. 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.   A client who states she did not get a promotion because her boss dislikes her
B.    A client whose partner died 5 years ago still talks about him in the present tense.
C.    A client who states she will worry about her grades after she finishes planning a party.
D.   A client who has stomach pain before presenting a project to his coworkers.
 
 
57. 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?
A.   Encourage the client to watch television as distraction.
B.    Encourage the client to describe their feelings in a journal
C.    Administrate a dose of alprazolam to the client
D.   Administrate a dose of atomoxetine to the client
 
 
58. A nurse is reviewing the medication administration record of a client who has major depressive and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?
A.   Calcium carbonate
B.    Warfarin
C.    Fluoxetine
D.   Acetaminophen
 
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60. A nurse in a long- term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?
A.   Neuropathy
B.    Hypertension
C.    WBC count 13, 000/ mm3
D.   BUN 16 mg/dl
 
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62. A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
 
A.   Reacting to the nurse as though she were his mother
B.    Talking negatively about other stuff members
C.    Refusing to participate in group activities
D.   Expressing frustration regarding unit rules.
 
 
63. 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?
A.   Withhold the next dose of the medication.
B.    Apply hydrocortisone cream on the client's rash
C.    Ask the client about a recent change in laundry detergent
D.   Explain that the medication causes a temporary rash.
 
64. A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive (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?
 
A.   Ask the client's family to encourage the client to receive ECT.
B.    Tell the client he cannot refuse the treatment because he was involuntarily committed.
C.    Inform the client that ECT does not require client consent.
D.   Document the client's refusal of the treatment in the medical record.
 
 
65. A nurse is caring for client who has been taking valproic acid. Which of the following is an expected outcome of the medication?
A.   The client reports absence of auditory hallucinations
B.    The client has decreased anxiety
C.    The client has decreased euphoric mood
D.   The client reports improved short - term memory
 
 
66. A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?
A.   The client expresses feelings of guilt.
B.    The client is unable to perform basic hygiene tasks.
C.    The client relocates from a house to an apartment
D.   The client gives away some of the partner's belongings.
 
 
67. A nurse is assessing a client who is restless and constantly mutters to himself. which of the findings should lead the nurse to suspect delirium?
A.   The client has a flat affect
B.    The client 's manifestations developed suddenly
C.    The client's speech is slow and repetitious
D.   The client is unable to recognize objects.
 
68. A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory report should the nurse report to the provider?
A.   Platelet's 100, 000/ mm3
B.    WBC count 8, 000/ mm3
C.    hemoglobin 16 g/dL
D.   RBC count 4.9 million/ mm3
 
 
69. 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's personal coping skills?
A.   "Can you describe how you are currently feeling?"
B.    "How does this situation affect your life?"
C.    "Do you see yourself current situation affecting your future?"
D.   "How have you dealt with similar situations in the past?"
 
 
70. A nurse on an acute care unit is caring for a newly- admitted client who has anorexia nervosa. When the nurse prepares to obtain a morning weight, the client becomes agitated. Which of the following statement should the nurse make?
A.   "You don't have to look at your current weight if you don't want to."
B.    "Why are you upset about us checking your weight today."
C.    "we can check your weight tomorrow when you are feeling better."
D.   "if you think you've gained too much weight, we can adjust your meal intake."
 
 
 
 
 
 

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