a nurse is obtaining a medical hx from a pt. who is requesting a prescription for bupropion for smoking cessation. which of the following assessment
... [Show More] findings in the pts. hx should the nurse report to the provider?
A. Recent head injury
b. hypothyroidism
c. herpes infection
d. knee arthroplasty 1 month ago
A. Recent head injury - risk for seizures
a nurse is planning care for a pt. who has narcissistic personality disorder. which of the following actions is appropriate for the nurse to include in the plan of care?
A. request an anti-psychotic med from the provider
b. ask the client to sign a no suicide contract
c. remain neutral when communicating with the client
d. provide the client with high cal. finger foods
c- remain neutral when communicating with the client
a nurse is preparing for an inter professional team meeting regarding client who has major depressive disorder. which of the following findings obtained during the initial assessment is a priority to report to other disciplines?
A. significant weight loss
b. neglected hygiene
c. psychomotor retardation
d. problem solving skills
c. psychomotor retardation
a nurse in a mental health facility is reviewing a client's medical record. which of the following actions should the nurse take first?
A. initiate 0.9 sodium chloride with 40 mil equivalent potassium chloride
b. encourage the client to attend group therapy sessions
c. teach the client about nutritional needs
d. administer acetaminophen 500 mg PO
d. administer acetaminophen 500 mg PO
a nurse is providing care for a client who demonstrates prolonged depression related to the loss of her significant other 6 months ago. which of the following actions should the nurse take?
A. suggest that the client avoids social interactions that remind her of her partner
b. discourage the client from reliving the event surrounding her loss
c. explain that it could take a year or more to learn to live with the loss
d. have the client maintain an unstructured daily routine
c. explain that it could take a year or more to learn to live with the loss
a nurse is teaching a client who has a new prescription for disulfiram. which of the following statements by the client indicates an understanding of the teaching?
A. I can continue to eat age cheese and chocolate
b.i can wear my cologne on special occasions
c. when I bake my favorite cookies, I can use pure vanilla extract for flavoring
d. if I cut myself I can clean the wound with isopropyl alcohol
A. I can continue to eat age cheese and chocolate
a nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations which of the following actions should the nurse take first?
A. focus the client on reality based topics
b. monitor the client for indications of anxiety
c. ask the client what she/he is hearing
d. encourage the client to listen to music
c. ask the client what she/he is hearing
a nurse is assessing a client who has delirium. which of the following findings requires immediate intervention by the nurse?
A. rapid mood swings
b. inappropriate speech patterns
c. command hallucinations
d. impaired memory
c. command hallucinations
a nurse in an ED is assessing a client who recently reported using ...... which of the following clinical manifestations should the nurse report?
A. lethargy
b. brady
c. hypertension
d. hypotension
c. hypertension
a nurse is teaching a client about cognitive reframing for stress management. which of the following client statements indicates understanding of the teaching
A. I will practice replacing negative thoughts with positive self thoughts
b. I will progressively relax each one of my muscle groups when feeling stressed
c. I will focus on a mental image while concentrating on my breathing
d. I will learn how to voluntarily control my b/p and HR
A. I will practice replacing negative thoughts with positive self thoughts
a nurse in a inpatient mental health facility is assessing a client who has Schizophrenia and is taking haloperidol. which of the following clinical findings is the nurses priority?
A. high fever
b. urinary hesitancy
c. insomnia
d. headache
A. high fever
a nurse is interviewing a client who was recently sexually assaulted. the client cannot recall the attack. the nurse should identify the client is using which of the following defense mechanisms?
A. Suppression
b. reaction formation
c. sublimation
d.repression
d. repression
a nurse is caring for a client who has Alzheimer's disease. which of the following findings should the nurse expect?
A. excessive motor activity
B. altered LOC
c. failure to recognize familiar objects
d. rapid mood swings
c. failure to recognize familiar objects
a nurse in a mental health facility is caring for a client who is being aggressive toward other clients. which of the following actions is a priority for the nurse to take?
A. ask the client if he intends to harm others
b. role model healthy ways to express anger
c. assist the client to explore techniques to reduce stress
d. suggest that the client make a list of things that make him angry
A. ask the client if he intends to harm others
a nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. which of the following actions should the nurse take?
A. request of the clients guardian to sign the consent
b. ask the charge nurse to obtain informed consent
c. contact the social worker to obtain the consent
d. explain implied consent to the clients family
A. request of the clients guardian to sign the consent
a nurse is developing a plan of care for school age child who has autism spectrum disorder. which of the following interventions should the nurse include In the plan?
A. assigns a child to a room with another child of the same age
b. discourage the child from making eye contact with caregiver
c. allow flexibility in the Childs daily schedule
d. use a reward system for appropriate behavior
d. use a reward system for appropriate behavior
a nurse in an outpatient clinic is assessing a client who has anorexia nervosa. which of the following findings indicates a need for hospitalization?
A. K 3.8
b. HR 56/min
c. temperature 96.1 F
d. weight 10% below ideal weight
c. temperature 96.1 F
a nurse is caring for a client who has severe depression and is scheduled to receive ECT. the nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?
A. muscle distress
b. aspiration
c. elevated b/p
d decrease HR
A. muscle distress
a nurse is developing a plan of care for a client who has paranoid personality disorder. which of the following actions should the nurse include in the plan?
A. provide written information about the clients treatment plan
B. monitor the client for splitting behaviors
c. encourage countertransference when developing the nurse client relationship
d. isolate the client from social or group interactions
d. isolate the client from social or group interactions
a nurse is caring for a client who has schizophrenia. the clients employer calls to discuss the clients condition. which of the following is appropriate nursing action?
A. consult the clients family
b. contact the facility legal department
c. contact the provider
d. consult the client
d. consult the client
a nurse in the ED is caring for a client who has serotonin syndrome. the nurse should assess the client for which of the following manifestations?
A. Brady
b. priapism
c. paresthesia
d. hyperpyrexia
d. hyperpyrexia - temp < 104F
a nurse is caring for a client who has bipolar disorder. the client is walking in and out of rooms speaking inappropriately, and giggling. which of the following actions should the nurse take?
A. tell the client there will be negative consequences for his/her behavior
b. have the client return to her room to read a book
c. lead the client outside for a walk
d. take the client to the day room to watch a movie with other clients
c. lead the client outside for a walk - provide outlet for physical activity
a nurse is admitting a client who has a new diagnosis of schizophrenia and history of aggressive behavior. which of the following actions should the nurse include in the clients initial plan of care?
A. ignore the clients hallucinations
b. agree with the client when he/she is upset until able to calm down
c. avoid eye contact with the client for the first few days
d. provide a physical exercise activity for the client
d. provide a physical exercise activity for the client
a nurse is caring for a client who begins yelling and pacing around the room. which of the following actions should the nurse take? SATA
A. stand directly in front of the client
b. speak to the client in a loud voice
c. request that security guards restrain the client
d. identify the clients stressors
e. talk to the client using short, simple sentences
d. identify the clients stressors
e. talk to the client using short, simple sentences
a nurse is observing a newly licensed nurse administer an IM medication to a client who is manic and refuses the medication. which of the following actions should the nurse take first?
A. talk to the newly licensed nurse about the incident
b. call the provider for an alternate medication route
c. stop the newly licensed nurse from administering the medication
d. report the occurrence to the nurse manager
c. stop the newly licensed nurse from administering the medication
a nurse is teaching the family of a client who has Alzheimers disease about safety interventions for night time wondering. which of the following interventions should the nurse include?
A. install locks at the bottom of the exit doors
b. place a clients mattress on the floor
c. encourage the client to take naps during the day
d. place rubber back throw rugs on the tile floors
b. place a clients mattress on the floor
a nurse is assessing a client who has schizophrenia. the client tells the nurse, "my heart exploded and my blood is draining out." the nurse should interpret that statement as which of the following manifestations?
A. somatic delusion
b. visual hallucination
c. concrete thinking
d. paranoia
A. somatic delusion
a nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has ADHD available is 10mg/5mL. how many mL? round to the nearest tenth.
12.5mL
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. encourage physical activity for the client during the day
b. discourage the client from expressing feelings of anger
c. keep a bright light on in the clients room at night
d. identify and schedule alternate group activities for the client
A. encourage physical activity for the client during the day [Show Less]