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
... [Show More] 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
morning and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client’s appetite and pattern of sleep.
B. Assess the client’s feelings about the hospital stay.
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on the client every 30 minutes.
Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview?
A. Client’s medication history includes the frequent use of antidepressants.
B. Describe self as a social drinker who drinks alcoholic beverages daily.
C. Reports difficulties with short term memory since traumatic brain injury.
D. Medical history includes that the client was recently sexually assaulted.
A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distract her by offering her finger foods.
D. Ignore the client’s acting out behavior.
A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client’s behavior?
A. Ineffective protection to guard self from internal or external threats.
B. Risk for injury related to inability to communicate.
C. Risk prone health behavior related to self-esteem assault.
D. Anxiety related to real or perceived threat to physical integrity.
A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client?
A. Decreased bowel movements. B. Presence of a dry mouth.
C. Decreasing hand tremors.
D. Increased mouth movements.
A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?
A. Visual hallucinations.
B. Auditory hallucinations.
C. Excessive motor activity. D. Delusions of persecution.
A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?
A. Explain to the client that her behavior invades the rights of the nursing staff.
B. Ask the client to explain why she is keeping a detailed record of her nursing care.
C. Teach the client strategies to control her obsessive compulsive behavior.
D. Encourage the client to express her feelings regarding the upcoming procedure.
During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
A. Assist the client in developing alternative coping skills.
B. Remain calm and use a matter of fact approach.
C. Ask the client why she is so anxious
D. Administer a PRN sedative to help relieve her anxiety.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
A. Acute confusion.
B. Ineffective community coping
C. Disturbed sensory perception.
D. Self-care deficit.
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
A. Tell me what you think should happen.
B. How serious was the collision?
C. What do you think you should do?
D. Call for transportation to the hospital.
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
A. Ineffective sexual patterns.
B. Impaired environmental interpretation.
C. Disturbed sensory perception.
D. Compromised family coping.
When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take?
A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether or not he takes it.
D. Explain to the client that the dosage has been changed.
The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide?
A. “You can watch T.V as much as you want outside of your room.”
B. “Sometimes clients feel like the T.V is sending them messages.” C. “It’s important to be out of you room and talking to others.”
D. “Watching T.V is a passive activity and we want you to be active.”
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 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. [Show Less]