1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates.
Which of the following treatment approaches should
... [Show More] the nurse plan to take?
a)Restrict participation in group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment - c)Maintain close observation
2. Clients who have borderline personality disorder are at risk for self-harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury
3. A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil.
What action should the nurse take? - Administer the medication at bedtime.
4. A nurse is caring for a client who reports that the television set in the room is really a two-way
radio and states, "voices are coming from the TV and everything we say in this room is being
recorded." What response should the nurse make? - "That must be very frightening."
5. The nurse should respond to the client's delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the
nurse-client relationship.
6. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder.
What finding should the nurse expect? - Confusion.
7. The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.8. A nurse is providing teaching to a client who has generalized anxiety disorder and a new
prescription for buspirone. The nurse should inform the client that which manifestations is a
common adverse effect of this medication? - Dizziness.
9. The nurse should inform the client that dizziness is a common adverse effect of buspirone. The
nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.
10. A nurse is reviewing the medical record of a client who has a new prescription for a
benzodiazepine. What finding should the nurse question the provider's prescription? -
Hypotension.
11. The nurse should question the provider's prescription for a benzodiazepine for a client who has
hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for
cardiac arrest.
12. A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding
is the priority for the nurse to report to the provider? - Elevated blood pressure.
13. The nurse should identify that the greatest risk to the client is an elevated blood pressure, which
increases the risk for a hypertensive crisis that can result from taking an MAOI, such as
phenelzine. The nurse should apply the safety and risk reduction priority-setting framework
when assessing this client. This framework assigns priority to the factor or situation posing the
greatest safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the
ABC priority-setting frame-work, or nursing knowledge to identify which risk poses the greatest
risk.
14. A nurse is providing teaching to a client who has a new prescription for disulfiram for the
management of alcohol dependence. What dietary choices should the nurse instruct the client
to avoid? - Pure vanilla extract.
15. The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as
pure vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiramalcohol reaction, which is manifested by hyperventilation, dizziness, vomiting, and hypotension.16. A nurse is providing teaching to the parents of a school-age child who has attention deficit
hyperactivity disorder (ADHD).What should the nurse include in her teaching? - Ignore your
child's attention-seeking behaviors that are not dangerous
17. A nurse is planning a staff education session about the administration of antidepressant
medications to older adult clients. What should the nurse include in the teaching? - Older adult
clients require a lower initial dose of antidepressant medication than adult clients
18. A nurse is caring for a client who has major depressive disorder and is severely withdrawn. What
techniques should the nurse use to facilitate communication with the client? - Speak to the
client using simple and concrete terminology
19. A nurse in a substance use disorder treatment facility is reviewing the medication records for a
group of clients. The nurse should expect to administer methadone for a client who has a
substance use disorder for what substance? - Opiates.
20. Opiates include opium, morphine, codeine, methadone, and heroin. Methadone is given as a
substitute to prevent cravings and severe manifestions of opiate withdrawal.
21. A nurse is performing an admission assessment for a client who has restricting type anorexia
nervosa. What finding should the nurse expect? - Decreased caloric intake.
22. A nurse in an acute mental health facility is caring for a client who is experiencing an acute
manic episode. What is the nurses priority? - Protect the client from impulsive behavior.
23. A nurse in the emergency department is assessing a client who has heroin intoxication. What
should the nurse expect? - Respiratory depression
24. A nurse is caring for a client who is receiving treatment for alcohol detoxification. What
medication should the nurse expect to administer during this phase of the client's care? -
Diazepam
25. Anti-anxiety agents, such chlordiazepoxide and diazepam, are long-acting CNS depressants that
are used to minimize the manifestations of alcohol withdrawal26. A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The
client is admitted under court order following the theft and destruction of a car. What behaviors
should the nurse expect the client to display? - Anger with the nursing staff for hospitalizing him
against his will
27. A nurse is planning care for a client who has bipolar disorder and is experiencing a manic
episode. What intervention should the nurse include in the plan? - Provide the client frequently
with high-calorie finger foods.
28. A nurse is assessing a client who has conduct disorder. What finding should the nurse expect? -
Aggressive behaviors towards others
29. A nurse is teaching a client who has agoraphobia about systematic desensitization. What
comment should the nurse include in the teachings? - You will slowly be exposed to increasing
level of public spaces
30. A nurse is interviewing a client who has anorexia nervosa. What findings should the nurse
expect? - Strenuous excercise regimn
31. A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing
morning hygience care. What action should the nurse take? - Talk to the client from two armlengths away.
32. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing
acute mania. What client goals should the nurse identify as a priority? - Maintaining adequate
hydration.
33. A nurse is speaking to a community group about the diagnosis and treatment of clients who
have Alzheimer's disease. The nurse should conclude that a member of the group requires
further teaching when she identifies what manifestation of the disease? - Sudden confusion
34. A nurse is assessing a client who has Stage 4 Alzheimer's disease. What finding should she
expect? - The client is able to identify the names of family members.35. A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription
of lithium. The nurse should identify that it is safe to administer what medication while the
client takes lithium? - Valproic acid.
36. A nurse in a mental health unit is planning care for a client who is receiving treatment for selfinflicted injuries. The nurse should identify what interventions as the priority when planning
care for this client? - Promoting and maintaining client safety
37. A nurse is providing teaching to the family of a client who has Alzheimer's disease about
donepezil. What statement should the nurse include in her teaching? - Donepezil can improve
cognitive functioning during the earlier stages of the disease
38. A nurse is planning care for a client who has a physical dependence to alprazolam and must
discontinue the medication. WHAt action should the nurse include in the plan? - Taper the
medication gradually over several weeks
39. A nurse in the emergency department is caring for a toddler who has a fractured arm. What
findings should the nurse identify as a possible indication of physical abuse? - The parent
provides history that is inconsistent with the child's injury
40. A nurse in an acute mental health facility is reviewing the medication records for a group of
clients. The nurse should expect a prescription for memantine for a client who has what
diagnosis? - Severe Alzheimer's disease
41. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and
to improve cognitive function [Show Less]