When preparing to administer a prescribed medication to a homeless male ata
community clinic, the client tells the RN that he usually takes a
... [Show More] different
dosage. What action should the RN take?
A. Tell him to take the medication then verify the dosage at the next
healthcare team meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether
or not he takes it.
D. Explain to the client that the dosage has been changed.
The nurse orients a female client with depression to the new room on the
mental health unit. The client states “It seems strange that I don’t have a T.V
in my room.” Which statement would be best for the RN to provide?
A. “You can watch T.V as much as you want outside of your room.”
B. “Sometimes clients feel like the T.V is sending them messages.”
C. “It’s important to be out of you room and talking to others.”
D. “Watching T.V is a passive activity and we want you to be active.”
A client admitted with a closed head injury after a fall has a blood alcohol
level of 0.28 (28%) and is difficult to arouse. Which intervention during the
first 6 hours following admission should the RN identify as the priority?
A. Give lorazepam (Ativan) PRN for signs of withdrawal.
B. Administer disulfiram (Antabuse) immediately.
C. Place in a side lying position with head of bed elevated.
D. Provide thiamine and folate supplements as prescribed.
The RN is completing the admission assessment of an underweight
adolescent who is admitted to a psychiatric unit with a diagnosis of
depression. Which finding requires notification to the HCP?
A. Potassium level of 2.9 mEq/dl.
B. Blood pressure of 110/70 mmHg.
C. WBC of 10,000mm^3.
D. Body mass index of 21.
The Rn is planning client teaching for a 35-year-old client with alcoholic
cirrhosis. Which self-care measure should the RN emphasize for the client’s
recovery?
A. Support group meetings.
B. Vitamin B and multivitamin supplements.
C. Diet with adequate calories and protein.
D. Alcohol abstinence.
A teenager has lost 20 pounds in the last three months is admitted to the
hospital with hypotension and tachycardia. The client reports irregular
menses and hair loss. Which intervention is most important for the RN to
include in the clients plan of care?
A. Implement behavioral modification therapy.
B. Initiate caloric and nutritional therapy.
C. Evaluate the client for low self-esteem.
D. Record daily weights and graft trend.
While interviewing a client, the nurse takes notes to assist with accurate
documentation later. Which statement is most accurate regarding notetaking during an interview?
A. The client’s comfort level is increased when the RN breaks eye contact
to take notes.
B. The interview process is enhanced with note taking and allows the
client to speak at a normal pace.
C. Taking notes during an interview is a legal obligation of examining RN.
D. The RN’s ability to directly observe the client’s non-verbal
communication is limited with note taking.
A client is receiving substitution therapy during withdrawal from
benzodiazepines. Which expected outcome statement has the highest
priority when planning nursing care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
A client who is being treated with lithium carbonate for manic depression
begins to develop diarrhea, vomiting, and drowsiness. What action should
the nurse take?
a. Notify the physician immediately and force fluids.
b. Prior to giving the next dose, notify the physician of the
symptoms.
c. Record the symptoms and continue medication as prescribed.
d. Hold the medication and refuse to administer additional amounts
of the drug.
While caring for an older client, the RN observes multiple bruises in
Over the client’s legs, arms, back, and gluteal areas. When the client
Contact, the RN suspects elder abuse. What action should the RN take?
A. Report family conversations and anger towards the client when
visiting.
B. Ask the client specific questions about someone causing the bruising.
C. Question the family members and caregiver how the bruising occurred.
D. Measure and document size, shape and color of the bruised areas.
The RN is performing intake interviews at a psychiatric clinic. A female client
with a known history of drug abuse reports that she had a heart attack four
years ago. Use of which substance places the client at highest risk for
myocardial infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana
After receiving treatment for anorexia, a student asks the school RN for
permission to work in the school cafeteria as part of the school’s work study
program. What action should the RN take?
A. Suggest that the student work in the athletic department.
B. Determine the parent’s opinion of the work assignments.
C. Refer the student to a psychiatrist for further discussion.
D. Recommend assignment to the receptionist’s office.
A client who is homeless is diagnosed with schizophrenia and admitted on an
involuntary basis to a mental health hospital 4 days ago. The client stopped
taking prescribed antipsychotic drugs approximately one month ago. Since
hospitalization the client continues to have poor judgment and refuses all
medications. What action should the RN take?
A. Encourage the client to stay in the hospital so the client does not have
to be homeless.
B. Provide the client with medication if the client presents an imminent
risk to self and others.
C. Administer a long acting antipsychotic medication so that the client
can be discharged to a shelter.
D. Describe to the client treatment options provided at the community
mental health clinics.
A male client comes to the emergency center because he has an erection
that will not resolve. The client reports that he is taking trazodone (Desyrel)
for insomnia. Which information is most important for the nurse ask the
client?
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
On admission to the mental health unit, a client diagnosed with
schizophrenia tells the RN that he is the son of god. Based on this statement,
which intervention should the RN include in this client’s plan of care?
A. Lead the client by his arm to the seclusion room.
B. Ensure the client’s environment is safe.
C. Schedule activity therapy twice a week.
D. Confront his delusion as not consistent with reality.
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. Loss 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.
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.................................................... [Show Less]