A client with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priority for this client?
A. Los... [Show More] s of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem.
The RN is preparing medications for a client with bipolar disorder and notices
that the client discontinued antipsychotic medication for several days. Which
medication should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
A female client requests that her husband be allowed to stay in the room
during the admission assessment. When interviewing the client, the RN notes
a discrepancy between the client’s verbal and nonverbal communication.
What action does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client’s husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client’s verbal
messages.
D. Integrate the verbal and nonverbal messages and interpret them as
one.
A male client approaches the RN with an angry expression on his face and
raises his voice, saying “My roommate is the most selfish, self-centered,
angry person I have ever met. If he loses his temper one more time with me,
I am going to punch him out!” The RN recognizes that the client is using
which defense mechanism?
A. Denial.
B. Projection.
C. Rationalization.
Your text here 1
D. Splitting.
A male client with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and the RN finds him attempting
to drink water from the bathroom sink faucet. Which intervention should the
RN implement?
A. Report the client’s serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
The RN is teaching a client about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What information should the client
acknowledge understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user.
A male client with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago.
Which question is most important for the RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear?
During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress job is causing trouble
in his personal life. He further explains that he often gets so angry while
driving to and from work that he has considered “getting even” with other
drivers. How should the RN respond?
A. “Anger is contagious and could result in major confrontation.”
B. “Try not to let your anger cause you to act impulsively.”
C. “Expressing your anger to a stranger could result in an unsafe
situation.”
D. “It sounds as if there are many situations that make you feel angry.”
A client who has agoraphobia (a fear of crowds) is beginning desensitization
with the therapist, and the RN is reinforcing the process. Which intervention
has the highest priority for this client’s plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd.
Which nursing actions are likely to help promote the self-esteem of a male
client with modern depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
A male client is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of
Risperidone (Risperdal). When the client walks to the nurse’s station in a
laterally contracted position, he states that something has made his body
contort into a monster. What action should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine
(Mellaril).
B. Offer the client a prescribed physical therapy hot pack for muscle
spasms.
C. Direct client to occupational therapy to distract him from somatic
complaints.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for
dystonia.
A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by the
RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
A client on the mental health unit is becoming more agitated, shouting at the
staff, and pacing in the hallway. When the PRN medication is offered, the
client refuses the medication and defiantly sits on the floor in the middle of
the unit hallway. What nursing intervention should the RN implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge. [Show Less]
