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
... [Show More] 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. [Show Less]