A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What
... [Show More] action is most important for the RN to take?
A. Offer the client a safe place to relax before interviewing her.
B. Ask the client to describe why she is being stalked.
C. Recommend that the client talk with a social worker.
D. Assure the client that the HCP will see her today.
The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take?
A. Explore the client’s feelings about his pets and home life.
B. Encourage his peers to help involve him in the activity.
C. Give the client permission to leave and return in 10 minutes. D. Redirect him by encouraging him to read from the handout.
A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take?
A. Report the behavior to the next shift.
B. Offer to play a game of cards with the client.
C. Document the behavior in the chart.
D. Plan to talk with the client the next day.
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
A. Do not take any over the counter meds.
B. Eat a high carb, low fat, low protein diet.
C. Call the crisis hotline if feeling lonely.
D. Avoid exposure to large crowds.
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. Refer the student to a psychiatrist for further discussion. B. Recommend assignment to the receptionist’s office.
C. Suggest that student work in the athletic department.
D. Determine the parent’s opinion of the work assignment.
The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain?
A. Motivation of treatment.
B. History of substance use.
C. Medication compliance. D. Mental status examination.
A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client’s plan of care?
A. Risk for suicide. B. Sleep deprivation.
C. Situational low self-esteem.
D. Social isolation.
A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer?
A. Haloperidol (Haldol).
B. Thiamine (Vitamin B1).
C. Diphenhydramine (Benadryl).
D. Lorazepam (Ativan).
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s rooms. The RN decides that the client needs constant observation based on which of these assessment findings?
A. Wanders into the clients rooms.
B. Refuses antipsychotic medications.
C. Talks with nonsensical words.
D. Disrupts group activities.
A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/
A. “Let’s go ask another RN is this is true.” B. “My name tag shows that I am a RN here.”
C. “I can’t possibly be one if your children.”
D. “I know that you don’t have 20 children.”
A high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent?
A. National percentile of weight and height.
B. Frequency of bingeing and purging behaviors.
C. Perceptions of family and social relationships.
D. School grades and extracurricular activities.
Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
A. Encourage the client to increase fluid intake.
B. Obtain the client’s serum Vicodin level.
C. Observe the client for further narcotic effects.
D. Determine the client’s reason for attempting suicide.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. What action should the charge RN implement?
A. Reassure the client that his request will be met whenever possible.
B. Advise the client that assignments are not based on the client’s request.
C. Ask the client to explain why he constantly requests the RN.
D. Encourage the client to verbalize his feelings about the RN.
The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the [Show Less]