A. Place the child in seclusion
1. A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other
... [Show More] children in the unit. Which of the following actions should the nurse take first?
a. Place the child in seclusion
b. Use therapeutic hold technique
c. Apply wrist restraints
d. Administer risperidone
A. Dependent
3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?
a. Dependent
b. Paranoid
c. Borderline
d. Histrionic
c. Offer the client the medication at the next scheduled dose time
4. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take?
a. Inform the client that he does not have the right to refuse medication
b. Administer the medication to the client via IM injection
c. Offer the client the medication at the next scheduled dose time
d. Implement consequences until the client take the medication
D. Offer prophylactic medication to prevent STIs
5. A nurse is caring for a client in the emergency department who states she was beaten and sexually assault by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
a. Conduct a pregnancy test
b. Requests mental health consultation for the client
c. Provide a trained advocate to stay with the
prophylactic medication client.
d. offer prophylactic medication to prevent STIs
B. Cancel the schedule ECT procedure
6. A nurse is caring for a client who has major depressive disorder. After discussing the treatment with
his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
a. Request that the client's partner sign the consent
form
b. Cancel the schedule ECT procedure
c. Proceed with the preparation for ECT based on implied consent
d. Inform the client about the risks of refusing the ECT
d. Displacement
7. 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?
a. Rationalization
b. Denial
c. Compensation
d. Displacement
b. It's important that the client feel safe verbalizing how she is feeling
8. A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client's depression. Which of the following statements by the nurse is appropriate?
a. Please don't take what the client said seriously when she is
depressed
b. It's important that the client feel safe verbalizing how she is feeling
c. Everybody feels that way about this client so don't worry about it
d. I'll change your assignment to someone who doesn't have depressive disorder
d. The child has cystic fibrosis
9. A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
a. The child is 10years old
b. The child is homeschooled
c. The has no siblings
d. The child has cystic fibrosis
b. Snap a rubber band on your wrist when you think about checking the locks
10. 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 technique?
a. Keep a journal of how often you check the locks each night
b. Snap a rubber band on your wrist when you think about checking the locks
c. Ask a family member to check the lock for you at night
d. Focus on abdominal breathing whenever you go to check the locks
a. Bradycardia
11. A nurse is assessing a client who is experiencing alcohol withdrawal.For which of the following findings should the nurse anticipate administration of lorazepam/
a. Bradycardia
b. Stupor
c. Afebrile
d. Hypertension
d. Encourage the client to participate in family therapy
12. A nurse is creating a plan of care of a client who has anorexia nervosa.Which of the following intervention should the nurse include in the plan?
a. Weigh the client twice per day
b. Prepare the client for electroconvulsive therapy
c. Set a weight gain goal of 2.2kg (5lbs) per week
d. Encourage the client to participate in family therapy
d. Attachment to objects that spin
13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following finding should the nurse expect?
a. Readily initiates conversation
b. Enjoys imaginative play
c. Strong relationship with sibling and
peers
d. Attachment to objects that spin
b. Limit loud noises in the client's environment
14. A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
a. Secure the client's valuable possessions
b. Limit loud noises in the client's environment
c. Encourage the client to participate in structured solitary activities
d. Provide high calorie snacks to the client
c. Reduce substance craving
15. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication.
a. Blocks aldehyde dehydrogenase
b. Prevents the anxiety of
abstinence
c. Reduce substance craving
d. Decreases the likelihood of seizures
b. Rationalization
16. A nurse in an alcohol treatment facility is caring for a client who states "my job is so stressful that the
only way I can come it is to drink." The nurse should recognize that the client is displaying which of the following defense mechanisms?
a. Repression
b. Rationalization
c. Introjection
d. Intellectualization
c. Can you describe how you are currently feeling?
17. 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. How does this situation affect your life?
b. Do you see your current situation affecting your
future?
c. Can you describe how you are currently feeling?
d. How have you dealt with similar situations in the past
d. Determine when the adolescent's change in behavior began
18. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following intervention is the nurse's priority at this time?
a. Contact the adolescent's parents
b. Suggest the adolescent join support groups
c. Ask the adolescent if he is considering hurting himself
d. Determine when the adolescent's change in behavior began
a. Slurred speech
19. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
a. Slurred speech
b. Hypotension
c. Bradycardia
d. Hyperthermia
B. Attention seeking
20. A nurse is assessing a client who has histrionic personality disorder. Which of the following finds should the nurse expect?
a. Lack of remorse
b. Attention seeking
c. Splitting of staff
d. Identity disturbance
a. I will limit my mothers clothing choices when she is getting dressed
21. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
a. I will limit my mothers clothing choices when she is getting dressed
b. I will provide my mother with detailed instructions about how to perform self-care
c. I will wake my mother up a couple of times in the night to check on her
d. I will discourage my mother from talking about physical complaints
a. Self-mutation
22. A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
a. Self-mutation
b. Pacing back and forth
c. Preoccupation with details d. Disorganized speech
d. Hgb 10 g/dL
23. a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?
a. Blood glucose 100 mg/dL
b. T4 11 mcg/dL
c. Potassium 3.7
mEq/L
d. Hgb 10 g/dL
a. This medication is given to help with extrapyramidal side effects
24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the
following statements should the nurse include in the teaching?
a. This medication is given to help with extrapyramidal side effects
b. This medication is given to help with your depression
c. Benztropine helps alleviate your hallucinations
d. Benztropine is used to counteract your tachycardia
a. Reinforce the clients orientation with the calendar
25. A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
a. Reinforce the clients orientation with the calendar
b. Refute the clients perception of visual hallucinations
c. Teach the client assertive techniques
d. Assigned the client to a different caregiver each shift
c. Encourage physical activity for the client during the day
26. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
a. Discouraged client from expressing feelings of anger
b. Identify and schedule alternative group activities for the
client
c. Encourage physical activity for the client during the day
d. Keep a bright light on in the clients room at night
b. Assign the same staff to care for the client each day
27. A nurse is caring for a client who has post traumatic stress disorder related to military service. Which of the following actions should the nurse take?
a. Encourage the client to suppress feelings of trauma
b. Assign the same staff to care for the client each day
c. Address the client in an authoritative manner
d. Limit the amount of time spent with the client [Show Less]