A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse
... [Show More] should ask which of the following questions to determine the client's ability to cope with this situation?
A) "Don't you think you'll get through this in time?"
B) "To whom do you talk when you feel overwhelmed?"
C) "Have you thought about rebuilding your home on the same site?"
D) "Would you like me to find a therapist for you to speak with?"
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?
A) "You probably want to hold your baby"
B) "I'll stay with you in case you want to talk"
C) "I know how you must be feeling"
D) "It hurts now, but things will be better soon"
A nurse on a medical-surgical unit is assessing a client who sustained injuries 12hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?
A) Somnolence
B) BP 154/96
C) Pinpoint pupils
D) Blood glucose 210
A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking Donepezil. Which of the following statements should the nurse include in the teaching?
A) "Take this medication in the evening at bedtime"
B) "Expect this medication to reverse the effects of Alzheimer's disease"
C) "If you miss a dose, double the next dose"
D) "You can crush this medication in applesauce"
A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?
A) The program will help the client accept responsibility for his disorder
B) The client should obtain a sponsor before discharge for an increased chance of recovery
C) The client will need to identify individuals who have contributed to his disorder
D) The program will need a prescription from the client's provider prior to attendance
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take?
A) Ask the client to identify the bomb in the room
B) Initiate disaster protocols per facility policies and procedures
C) Assess the client for evidence of a perceptual disturbance
D) Convince the client that there is no bomb in her room
A nurse is admitting a client who has major depressive disorder and a new prescription for Tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?
A) Lansoprazole
B) Naproxen
C) Magnesium hydroxide
D) Phenylephrine
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?
A) Delusions
B) Neologisms
C) Anhedonia
D) Echopraxia
A nurse in an ED is caring for a female adolescent who has a diagnosis of bulimia nervosa and has a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis?
A) "She works so hard at ballet. Will she still be able to perform?"
B) "She won't let me take the trash from her room. I'm concerned about what she has in there"
C) "She told me she was tired, so I did her shores for her today"
D) "She is happier with her appearance now that she's lost some weight"
A nurse is assessing a client who has major depressive disorder and has been receiving Amitriptyline for 1wk. Which of the following outcomes should the nurse expect?
A) Rapid improvement in affect within 30-60min after taking the medication
B) Greater risk of attempting suicide as affect and energy improve
C) Onset of frequent loose stools
D) Development of physiologic dependence on the medication
A nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include?
A) Repeatedly talks about the traumatic incident
B) Sleeps excessively
C) Experience feelings of isolation
D) Uses repetitive speech
A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?
A) Weight loss 10% of total body weight in 3mo
B) Potassium 3.8
C) Temp. 96.1 F
D) HR 54bpm
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first?
A) Diazepam 5mg IV bolus
B) Clonidine 0.1mg transdermal patch
C) Naltrexone 380mg IM
D) Bupropion 150mg PO
A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it's the client's turn, she doesn't respond. Which of the following actions should the nurse take before repeating the request to the client?
A) Allow the client time to collect her thoughts
B) Prompts the client to give a response
C) Move on to the next client
D) Offer the client a suggestion for a goal
A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?
A) Call the provider to obtain an immediate prescription for restraints
B) Prepare to administer Benzodiazepine IM
C) Call for a team of staff members to help with the situation
D) Check the client who was hit for injuries
A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching?
A) Have a family member present during treatment
B) Increase fluid intake
C) Change position slowly
D) Wear sunglasses when outdoors
A client who has bipolar disorder is to be discharged home with a prescription for Lithium. Which of the following statements indicates that client teaching regarding the medication has been effective?
A) "I should eat a regular diet with normal amounts of salt and fluids"
B) "I should discontinue the Lithium when I begin to feel better"
C) "I need to be careful to avoid becoming addicted to the Lithium
D) "I can skip a dose of medication if my stomach is upset"
A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?
A) Allowing a client to choose which unit activities to attend
B) Attempting alternative therapies instead of restraints for a client who is combative
C) Providing a client with accurate information about his prognosis
D) Spending adequate time with a client who is verbally abusive
A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take?
A) Encourage the parents to avoid discussing the death with their other children in order to protect their feelings
B) Recommend each parent grieve in private to avoid hindering each other's healing
C) Suggest forming a weekly support group for parents who have experienced the loss of a child
D) Advise the parents to begin counseling if they are still grieving in a few months
A nurse in a mental health clinic is planning care for a client who has a new prescription for Olanzapine. Which of the following interventions should the nurse identify as the priority?
A) Advise the client to take frequent sips of water
B) Instruct the client to avoid driving during initial therapy
C) Consult a dietitian for a calorie-controlled diet plan
D) Recommend that the client exercise regularly
A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply)
A) Occupational therapy
B) Meal delivery services
C) Speech therapy
D) Physical therapy
E) Home health services
A nurse is reviewing lab results for a client who has schizophrenia and is taking Clozapine. Which of the following values should the nurse identify as a contraindication for receiving Clozapine?
A) WBC 2500
B) Hgb 11.5
C) Platelets 150,000
D) RBC 3.5 million
A nurse in an outpatient mental health setting is collecting a health history from a client who is taking Paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with Paroxetine?
A) St. John's wort
B) Saw palmetto
C) Echinacea
D) Ginkgo
A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A) "I will use the same plan of care and interventions for each client who has depression"
B) "Each individual nurse will develop a separate plan of care when managing clients who have depression"
C) "I will update the plan of care as a client's manifestations of depression change"
D) "An assistive personnel can use the plan of care for client teaching"
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?
A) The client needs excessive external input to make everyday decisions
B) The client demonstrates a dedication to his job that excludes time for leisure activities
C) The client adheres to rigid set of rules
D) The client has difficulty starting new relationships unless he feels accepted
A nurse is caring for a child who is taking Methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of Methylphenidate?
A) Weight gain
B) Tinnitus
C) Tachycardia
D) Increased salivation
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?
A) Controls anger outbursts to avoid being placed in seclusion
B) No longer exhibits a fear of social or public situations
C) Refrains from manipulating others o earn dining-room privileges
D) Imitates the therapist's use of relaxation techniques
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
A) Panic
B) Moderate
C) Severe
D) Mild
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?
A) Confront the staff member
B) Encourage the client to report the incident
C) Document the incident in the client's health record
D) Report the occurrence to the charge nurse
A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates tat the client is using a positive coping mechanism?
A) "I will limit my drinking to the weekends"
B) "I will stay in my room and avoid others when I'm feeling down"
C) "I will be dependent on others for the time being"
D) "I will attend daily group therapy sessions to practice relaxation techniques"
A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?
A) Document the client's behavior every 8hr
B) Limit the client's fluid intake to 50mL/hr
C) Renew the prescription for the client q4hr
D) Toilet the client q4hr
A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?
A) "I'm relieved now that my financial affairs are in order"
B) "It's easier to talk about my feelings now"
C) "Suddenly I have enough energy to do anything I want"
D) "Thank you for always taking such good care of me"
A nurse is reviewing routine lab values for several clients who are taking Lithium carbonate. Which of the following clients should the nurse assess further for findings indicating Lithium toxicity?
A) A client who has a fasting blood glucose of 80mg/dL
B) A client who has a sodium level of 128 mEq/L
C) A client who has a BUN of 18mg/dL
D) A client who has a potassium level of 3.6 mEq/L [Show Less]