Test 5
1. A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize
... [Show More] competitive games with the clients. Which of the following is an appropriate intervention?a) recommend a game of table tennis with another clientb) suggest the client exercise on a stationary bikec) take the client outside for a walkd) praise the client’s efforts to engage in social interaction
2. A nurse in a mental health facility is caring for a client in the busy facility dining room during lunchtime when suddenly the client becomes angry and throws a chair. Which of the following interventions should the nurse perform first?a) restrain the client to prevent injury to himself or othersb) place the client in a monitored seclusion room until he is calmc) administer a PRN antianxiety medicationd) attempt to talk the client down
3. A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?a) administering an anticonvulsantb) padding side rails to prevent injuryc) preparing for artificial ventilationd) applying a cooling blanket
4. A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?a) discourage rest periods during the daytimeb) instruct family to avoid visiting during mealtimesc) offer three or four large meals dailyd) give the client extra time to communicate needs.
5. A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which of the following statements indicates that the newly hired nurse understands when a tertiary intervention is needed?a) I should perform screenings to identify clients at risk for suicideb) I should recognize the lethality of the suicide planc) I should provide counseling for the family following the suicide of a clientd) I should provide a safe environment to prevent the client from committing suicide
6. A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?a) place the client in seclusion if visual hallucinations are presentb) limit the number of questions asked during assessmentsc) use frequent touch to provide client supportd) directly tell the client that delusions are not real
7. A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?a) warn the client that further disruptions will result in seclusionb) ignore the client’s behavior, realizing it is consistent with her illnessc) Set limits on the client’s behavior and be
consistent in approachd) ask the client to recommend consequences for her disruptive behavior
8. A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?a) maintain a nonjudgmental attitudeb) avoid displaying an emotional responsec) offer sympathetic supportd) verbalize disapproval of the client’s substance abuse
9. A nurse is reading the medical record for a client who has schizophrenia which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization?
a) I have broken off all my past relationships because my friends and family are trying to kill meb) I hear voices telling me that I have been badc) My hands and feet are much smaller than they used to bed) Everything in this room has changed and I don’t recognize it anymore
10. A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?a) monitor the client closely to prevent self-mutilationb) set limits to prevent exploitation of other clientsc) discourage flamboyant or seductive behaviorsd) give positive feedback when client is assertive with staff or clients.
11. A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?a) frequent manic episodesb) refusal of medication due to paranoiac) preoccupation with manifestations of various illnessd) involuntary loss of a sensory function
12. A nurse is collecting a health history on a client who has a diagnosis of Wernicke- Korsakoff syndrome. Which of the following is an expected finding?a) family history of Alzheimer’s diseaseb) personal history of alcohol use disorderc) undergoing current treatment of HIVd) current rehabilitation of opiate addiction
13. A nurse is talking with a client who has schizophrenia. Suddenly the client states, ‘I’m frightened. Do you hear that? The voices are telling me to do terrible things.’ Which of the following responses by the nurse is appropriate?
a) you need to tell the voices to leave you aloneb) you need to understand that there are no voicesc) what are the voices telling you to dod) why do you think you are hearing the voices
14. A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client’s discharge plan?a) contact the crisis counselor once a weekb) identify anxiety-producing situationsc) try to repress feelings of anxietyd) eliminate stress and anxiety from daily life.
15. A nurse is providing discharge teaching to a client with a new prescription of phenelzine. The nurse should instruct the client to avoid which of the following foods when taking this medication?a) salamib) cottage cheesec) shellfishd) frozen peas
16. A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, Hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?a) Tardive dyskinesiab) neuroleptic malignant syndromec) acute dystoniad) pseudoparkinsonism
17. A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching?a) you should change positions slowly while taking this medicationb) this medication is prescribed to help overcome alcohol addictionc) you should omit foods containing oxalates while taking phenelzine
d) you should avoid drinking liquids after your evening meal
18.A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder?a) recent history of stressful, positive life eventsb) past history of childhood traumac) being an only childd) having elevated levels of serotonin
19.A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?a) the client has begun playing basketball with several other clients during the past month.b) the client identifies with problems expressed by other clients.c) the client’s behavior has become impulsive in the past few weeksd) the client states she wants to go home to be with her children and partner
20.A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?a) shuffling gait
b) constant tapping of feet when sittingc) sudden onset of high feverd) twisting tongue movements
21.A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the client indicates understanding of the teaching?a) I may develop a slow heartbeat while taking bupropion.b) I can drink one glass of wine with dinner each day while taking bupropionc) I may not notice a lifting of my mood for at least 2 weeksd) I should watch for increased salivation and drooling while taking bupropion
22.A nurse is preparing to administer selegiline for a client who is admitted with major depression. Which of the following actions should the nurse take?a) apply to dry skin on the client’s upper thighb) administer subcutaneously in the client’s abdomen using a 27 gauge needlec) give the medication orally at bedtime to promote sleepd) inject the medication intramuscularly in a large muscle
23.A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding?a) death of client’s father two months agob) experiences frequent facial ticsc) suspended from school several times in the past yeard) adheres strictly to routines.
24.A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?a) provide a cognitively stimulating environmentb) rotate staff to prevent caregiver role strainc) limit the client’s choices for daily activitiesd) use confrontation to manage negative behavior
25.A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, ‘You are all making fun of me.” Which of the following behaviors is this client displaying?a) grandeurb) flight of ideasc) erotomaniad) ideas of reference
26.A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?a) sleeping 12 hr or more each dayb) increasing sense of attachment to othersc) constant need to talk about the eventd) increasing feelings of anger
27.A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?a) dementia is characterized by a sudden onset of confusionb) an altered level of consciousness is associated with dementiac) the signs of dementia are progressive and irreversibled) dementia can be triggered by a high fever or dehydration
28.A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer’s disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?a) this morning, this morning, this morningb) it was good. The Queen of England visited me therec) I just don’t remember what I did this morningd) Snip, snap. Take a nap
29.A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?a) prior physical health followed by the need for two surgeries within the last three monthsb) obsession over a fictitious defect in physical appearancec) sudden unexplained loss of peripheral sensationd) constant worry about the undiagnosed presence of an illness
30.A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?a) rotate staff assignments for this clientb) use touch to calm the client during periods of anxietyc) check the client’s mouth after the client takes medicationd) assign and assistive personnel to feed the client at mealtimes
31.A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do ‘bad things.’ The nurse correctly identifies this finding as which of the following?a) command hallucinationb) gustatory hallucinationc) cognitive distortiond) somatic delusion
32.A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, ‘The flakalas are here. The flakalas are here.’ The nurse correctly recognizes the client’s use of the word flakala as an example of which of the following alterations in speech?a) echolaliab) clang associationc) neologismd) word salad
33.A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, ‘I am the devil! I am God! Open the gate for me!’ Which of the following replies by the nurse requires intervention?a) it sounds frightening to feel like both God and the devil at the same timeb) I don’t understand. Can you tell me what that means?c) Are you saying that you are both good and bad?d) There is no gate for me to open
34.A nurse in the emergency department is planning care for a client who is admitted for an overdose phencyclidine (PCP). Which of the following actions should the nurse plan to take?a) administer warmed IV fluids to counteract hypothermiab) reverse the toxicity with naloxonec) verbally attempt to calm the clientd) administer ammonium chloride
35.A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?a) remain with the clientb) provide a diverting activityc) encourage verbalization of feelingsd) instruct the client to remember past coping mechanisms
36.A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?a) encourage family to take the client out of the facility for short periods of time.b) reward the client for her change in behaviorc) monitor the client’s whereabouts at all timesd) ask the client why her behavior has changed.
37.A nurse is caring for a client 3 day after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, ‘There’s no reason to go on living. I just want to end it all.” Which of the following actions should the nurse take?a) ask the client if she has a plan to commit suicideb) recognize the attempt at manipulation and escort the client back to her activityc) assist the client to her room and allow her to rest before resuming activityd) notify the client’s family and request a visitor to stay with the client until thoughts of suicide are gone.
38.A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should
the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?a) a client who ahs a WBC of 2900b) a client who has a hematocrit of 55%c) a client who has a serum potassium of
3.3 mEq/Ld) a client who has a BUN of 22 mg/dL
39.A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (select all that apply)a) muscle spasms of the neckb) fidgeting behaviorc) blurred visiond) termors of the handse) sexual dysfunction
40.A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?a) you are already too thin and exercise is not good for you. Go sit down somewhere and eat somethingb) come with me. Here is a milkshake to drinkc) we need you to decide what activities you will do todayd) you will need to leave the dining room right now and go somewhere else to exercise
41.A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?a) you really need to follow the rules of the unit and get out of bedb) if you do not get out of bed you will not receive your mealc) I will help you get ready and then you can rest after activitiesd) you should rest until you feel able to join the group
42.A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?a) increase your fluid and fiber intake to prevent constipationb) have your blood pressure checked frequently for hypertensionc) expect to have your blood checked weekly for serum electrolyte imbalancesd) increase caloric intake to prevent weight loss
43.A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client?a) diazepamb) Acamprosatec) naltrexoned) disulfiram
44.A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client’s current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following.a) a blood lithium level of 1.8 mEq/L is not within the maintenance treatment levelb) the lithium level is at the toxic levelc) the lithium level is below the therapeutic treatment leveld) the lithium levels is within the therapeutic level for initial treatment
45.A nurse is providing teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teaching?a) this medication will help prevent seizuresb) this medication
will be administered by intramuscular injection every 2 weeks.c) I should expect to develop ringing in my ears while taking this medicationd) I will rise slowly from a lying position to prevent fainting while taking this medication
46.A nurse is discussing the care of a client who has a conversion disorder with persistent aphasia with a newly licensed nurse. Which of the following statements should the nurse include about conversion disorder?a) conversion disorders are consciously triggeredb) the condition may relapse within a year
c) testing for a pathophysiological cause of aphasia is not necessaryd) clients with conversion disorder have a flat affect
47.A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client’s mania?a) fluvastatinb) carbamazepinec) lorazepamd) propranolol
48.A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching?a) I should expect relief from depression within 3 to 4 days.b) I will take my fluoxetine at bedtime so I can sleep better.c) I should notify my provider if I develop a skin rashd) I will notice an improvement in my sex drive
49.A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?a) oh, I’m so pleased that you finally put on clean clothesb) why did you wear clean clothes and comb your hair todayc) your mood must be lifting because you have on clean clothes and have combed your haird) I see that you have on clean clothes and have combed your hair
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?a) allow manipulation so as to not raise the client’s anxietyb) avoid discussing past behaviors with the clientc) institute consequences for manipulative behaviord) bargain with the client to discourage manipulative behavior [Show Less]