The daughter of a female client with stage-1 Alzheimer’s disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this
... [Show More] stage. What finding should the nurse tell the daughter is common?
A. Personality changes and agitation.
B. Alterations in communication.
C. Inability to recognize one’s location.
D. Depression and emotional lability.
*C
Physical examination of a school-aged child reveals several bite marks in various locations on the body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that the child is always having accidents. Which initial response is best for the nurse to make?
A. I need to inform the healthcare provider about your child’s tendency to be accident prone.
B. Boys this age always seem to require more supervision and can be quite accident prone.
C. Tell me more specifically about your child’s accidents.
D. I must report these injuries to the authorities because they do not seem accidental.
*C
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
A. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
B. Notify the health care provider of the symptoms prior to the next administration of the drug.
C. Hold the medication and refuse to administer additional amounts of the drug.
D. Notify the health care provider immediately and prepare for administration of an antidote.
*B
On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. 24 hours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate?
A. Bake a cake for a resident's birthday.
B. Participate in a group quilting project.
C. Clean the unit kitchen cabinets.
D. Watch television in the activity room.
*B
The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?
A. Encourage group participation.
B. Offer oral fluids.
C. Evaluate ECT effectiveness.
D. Monitor vital signs.
*D
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
A. Administer a prescribed PRN anti-anxiety medication.
B. Assist the client to identify stimuli that precipitates the ritualistic activity.
C. Teach the client relaxation and thought stopping techniques.
D. Allow time for the ritualistic behavior, then redirect the client to other activities.
*D
the charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
A. Encourage participation in activities.
B. Monitor appetite and observe intake at meals.
C. Provide ongoing, supportive contact.
D. Maintain safety in the client’s milieu.
*D
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, “There wasn't anything I could do to stop her drinking this morning.” What intervention should the nurse take at this time?
A. Tell the client that therapy cannot take place while she is intoxicated.
B. Have the client admitted to the inpatient psychiatric unit.
C. Arrange for emergency admission to a detoxification unit.
D. Talk to this spouse about strategies to limit the client’s drinking.
*A
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
A. Crickets are a good source of protein.
B. I have not heard any voices for a week.
C. Sometimes I have a hard time sitting still.
D. Only my belief in God can help me.
*D
A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, “You fat tub of lard! Get something done around here!” What is the best initial action for the nurse to take?
A. Tell the client his health care provider will be notified if he continues to be verbally abusive.
B. Redirect the client's energy by asking him to tidy the recreation room.
C. Call the health care provider to obtain a prescription for a sedative.
D. Have the orderly escort the client to his room.
*B
The wife of a male client recently diagnosed with schizophrenia asks the nurse, “What exactly is schizophrenia? Is my husband alright?” Which response is best for the nurse to provide to this family member?
A. It is a chemical imbalance in the brain that causes disorganized thinking.
B. I think you should talk to your husband psychologist about this question.
C. It sounds like you're worried about your husband. Let's sit down and talk.
D. Your husband will be just fine if he takes his medications regularly.
*A
A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?
A. The clinic health care provider.
B. His support group sponsor.
C. His case manager.
D. The emergency room nurse.
*C
Adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
A. Provide a structured environment with little stimuli.
B. Reinforce her ability to make her own decisions.
C. Encourage her to identify feelings of anger.
D. Schedule her to attend various group activities.
*A
A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? Select all that apply.
A. Obsessions cause compulsions.
B. Obsessive thoughts are linked to levels of neurochemicals.
C. Antidepressant medications increase serotonin levels.
D. Compulsions relieve anxiety.
E. Anxiety is the key reason for OCD.
*B, C, D, and E
A client who has been admitted to the psychiatric unit tells the nurse, “My problems are so bad that no one can help me.” Which response is best for the nurse to make?
A. Let's talk about what is right with your life.
B. Things probably are not as bad as they seem right now.
C. I hear how miserable you are, but things will get better soon.
D. How can I help?
*D
The nurse plans to help in 18-year-old female intellectually disabled client ambulate the first post operative day after her appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, “Get out of here! I'll get up when I'm ready!” Which response is best for the nurse to make?
A. Your health care provider has prescribed ambulation on the first postoperative day.
B. I know how you feel. You're angry about having to ambulate, but this will help you get well.
C. I'll be back in 30 minutes to help you get out of bed and walk around the room.
D. You must ambulate to avoid complications which could cause more discomfort than ambulating.
*C
An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
A. Distract the client whenever discomfort about being with others is expressed.
B. Confront fears and discuss the possible causes of these fears with the client.
C. Accompany the client outside for an increasing amount of time each day.
D. Plan an outing with the peer group within the first week of admission.
*C
Based on non-compliance with the medication regimen, an adult client with a diagnosis of substance abuse and schizophrenia recently had a change in prescriptions from oral fluphenazine HCI (Prolixin) to fluphenazine decanoate (Prolixin IM). What is most important to teach the client and family about this change in medication regimen?
A. The effects of alcohol and drug interaction.
B. Signs and symptoms of extrapyramidal effects (EPS).
C. Information about substance abuse and schizophrenia.
D. The availability of support groups for those with dual diagnosis.
*A
And older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and ask the nurse, “Where should I stand for the parade?” Which response should the nurse provide?
A. Remember I told you that this is a nursing home and I am your nurse.
B. Anywhere you want to stand as long as you do not get hurt by those in the parade.
C. Let's go back to the activity room and see what is going on in there.
D. You are confused because of all the activity in the hall. There is no parade.
*C
The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client history on admission to the hospital?
A. Determine if the client attends a support group weekly.
B. Have the client describe any recent changes in mood.
C. Ask the client if he takes St. John’s Wort routinely.
D. Hold all antidepressant medications until further notice.
*C
A client who reports feeling depressed tells the nurse on admission, “I want to feel normal again.” How should the nurse respond?
A. What do you think the hospital can do for you?
B. Tell me more about how things are with you.
C. How long have you felt this way?
D. We are all here to help you get better.
*B
A client who abuses alcohol says to the nurse, “I am glad I went in for treatment period now my problems with alcohol are all behind me.” Which response is best for the nurse to provide?
A. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you.
B. Yes, the treatment program you attend has an excellent success profile.
C. Do you know what one day at a time means for those who have problems with alcohol?
D. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you?
*D
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the health care provider.
Which response is best for the nurse to provide this client?
A. What concerns do you have at this time?
B. How can I help answer your questions?
C. Let me call and leave a message for your health care provider.
D. The health care provider should be here on Monday morning.
*C
The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression?
A. Grandiose ideations.
B. Self-destructive thoughts.
C. Suspiciousness of others.
D. A negative view of self in the future.
*D
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?
A. Eat foods high in fiber such as whole grain breads.
B. Keep your dietary salt intake consistent.
C. It may take three to four weeks to achieve therapeutic effects.
D. Avoid eating aged cheese and chicken liver.
*B
The nurse observes a female client with schizophrenia watching the news on television. She begins to laugh softly and says, “Yes, my love, I'll do it.” When the nurse questions the client about her comment she states, “The news commentator is my lover and he speaks to me each evening. Only I can understand what he says.” What is the best response for the nurse to make?
A. The news commentator is not talking to you.
B. What do you believe the news commentator said to you?
C. Does the news commentator have plans to harm you or others?
D. Let's watch news on a different television channel.
*B
A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, “Because he made me mad!” Which goal is best for the nurse to include in the client's plan of care?
A. Discuss recognizing consequences for behaviors exhibited.
B. Encourage client to verbalize feelings when anger occurs.
C. Teach the client to outline methods for managing anger.
D. Suggest actions to control impulsive responses towards self and others.
*D
The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the health care provider?
A. Restlessness, anxiety, and difficulty sleeping.
B. Agitation, vomiting, and visual and auditory hallucinations.
C. Global confusion and inability to recognize family members.
D. Low-grade fever, diaphoresis, hypertension, and tachycardia.
*C
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
A. Ask the health care provider to give the client the medication.
B. Explain that the diabetic medication is important to take.
C. Reassure the client that no one will harm her while she is in the hospital.
D. Reassess client's mental status for thought processes and content.
*D
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, “I think he took some of my pain pills.” During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents?
A. If he might have taken any other drugs.
B. If he has seemed depressed recently.
C. If he has a desire to quit taking drugs.
D. If a drug overdose has ever occurred before.
*A
A female client with depression attends group and states that she sometimes misses her medication appointment because she feels very anxious about riding the bus. Which statement is the nurses best response?
A. Let's talk about what happens when you feel very anxious.
B. Take your medication for anxiety before you ride the bus.
C. What are some ways that you can cope with your anxiety?
D. Can your case manager take you to your appointments?
*C
A client is responding to auditory hallucination and shakes a fist at a nurse and says, “Back off, witch!” The nurse follows the client to the unit dayroom. What action should the nurse implement?
A. Sit down in a chair near the client.
B. Move to a position that allows the client to be closest to the room's door.
C. Position self within an arm’s length of the client.
D. Ensure that there is physical space between the nurse and client.
*D
A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature 100 degrees Fahrenheit, 100 beats per minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem?
A. Knowledge deficit related to ineffective coping.
B. Risk for injury related to alcohol detoxification.
C. Health seeking behaviors related to personal crisis.
D. Risk for injury related to suicidal ideations.
*B
Which statement about contemporary mental health nursing practice is accurate?
A. There is one approved theoretical framework for psychiatric nursing practice.
B. The psychiatric nursing client may be an individual, family, group, organization, or community.
C. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.
D. Psychiatric nursing has yet to be recognized as a core mental health discipline.
*B
The nurse should withhold the next scheduled dose of a client haloperidol (Haldol) based on which assessment finding?
A. Dizziness when standing.
B. Shuffling gait and hand tremors.
C. Fever of 102 F.
D. urinary retention.
*C
Over a period of several weeks, a male participant of a socialization group at a community daycare Center for the elderly monopolizes most of the groups time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?
A. Ask the client to join another group.
B. Talked to the client outside the group about his behavior during group meetings.
C. Allow the group to handle the problem.
D. Remind the client to allow others in the Group A chance to talk.
*C
A schooled-aged girl with severe birth defects and mental retardation is brought to the emergency room because of a possible broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention should the nurse involvement?
A. Prepare the child for cast placement.
B. Evaluate the child for other injuries.
C. Evaluate the intellectual functioning of the child.
D. Ask the child to explain the accident.
*B
An adult male who is a sales manager tells the nurse, “I am thinking about a job change period I do not feel like I am living up to my potential.” Which of Maslow’s developmental stages is the client attempting to achieve?
A. Basic needs.
B. Safety and security.
C. Loving and belonging.
D. Self-actualization.
*D
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug?
A. My urine looks pink.
B. This pill gives me diarrhea.
C. My mouth feels like cotton.
D. That stuff gives me indigestion.
*C
An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the 4th day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate?
A. Immediately transfer the client to the intensive care unit.
B. Describe the symptoms to the charge nurse and record on the client's chart.
C. No action is required at this time as these are known side effects of such drugs.
D. Place the client on seizure precautions and monitor carefully.
*A
An adult female who is married and works full time in a factory has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question should the nurse use?
A. What did you do to deserve this?
B. How did this happen to you?
C. Did your husband beat you?
D. Do you drink excessively?
*B
At a support meeting for a parents of a teenager with polysubstance dependency, a parent states, “Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.” The nurses response should be based on which information?
A. Feelings of depression frequently lead to drug abuse and addiction.
B. Addiction is a chronic incurable disease.
C. Careful monitoring should be provided during withdrawal from the drugs.
D. Tolerance to the effects of drugs causes feelings of depression.
*C
And adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the clients clothing. Which action should the nurse take?
A. Explain to the client that his suspicions are false.
B. Place a lock on the client's closet.
C. Encourage the client to actively participate in assigned activities on the unit.
D. Ignore the client's paranoid ideations to extinguish these behaviors.
*C
The Nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
A. Increased self-understanding.
B. Loss of independence.
C. Isolation from society.
D. Development of intimate relationships.
*A
And adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?
A. Administer acetylcysteine (Mucocyst).
B. Monitor cardiac rhythm for flat T waves.
C. Check both serum AST and ALT levels.
D. Prepare to administer syrup of ipecac.
*A
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse’s mannerisms. Which mechanism is the client using?
A. Sublimation
B. Introjection
C. Repression
D. Identification
*D
The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include in the plan of care?
A. Teach the importance of medication compliance.
B. Focus on the client's positive or negative feelings towards the nurse.
C. Emphasize the client’s strengths and assets.
D. Offer the client psycho educational materials to read.
*B
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
A. I think you're getting well.
B. Others have had similar thoughts when under stress.
C. Did you really believe you were Jesus Christ?
D. Why did you think you were Jesus Christ?
*B
A woman arrives in the emergency center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the clients fear and anxiety, how should the nurse respond?
A. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
B. I would be very upset and mad if my best friend did that to me.
C. You must feel betrayed, but maybe you might have led him on?
D. This does not sound like rape. Did you change your mind about having sex after the fact?
*A
The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the health care provider informed him that he will be moving to a boarding home. What is the most important nursing problem for discharge planning?
A. Ineffective coping related to inadequate support.
B. Social isolation related to difficult interactions.
C. Ineffective denial related to situational anxiety.
D. Self-care deficit related to cognitive impairment.
*C
A client, who is on a 30 day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take?
A. Remind the client of the unit rules.
B. Tell the client to talk to his health care provider about his privileges.
C. Calmly address the client’s inappropriate behavior.
D. Call a staff member to escort the client to his room.
*C
A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
A. Tell the client that hospital guidelines allow only staff to pass the trays.
B. Provide an additional challenge by asking the client to help feed the older clients.
C. Suggest another way for this client to participate in the unit's activities.
D. Encourage the client's self-motivation by asking her to pass trays for the rest of the week.
*C
A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. Would action should the nurse implement?
A. Encourage him to share his feelings more appropriately.
B. Administer a PRN prescription for an anti-anxiety drug.
C. Expressed concern over his disappointment.
D. Arrange to have a clergy person visit.
*C
And older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first?
A. Has anyone in your family had hearing problems?
B. Are you ever alone when you hear the voices?
C. Do you see things that others cannot see?
D. Do you have problems with hallucinations?
*B
A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?
A. Encourage the client to emotionally accept the chronicity of the disease.
B. Assess priorities to be set for the client’s overall nursing care plan.
C. Inquire about emotional factors affecting the client's present condition.
D. Assist the client in verbalizing distress about the disease.
*C
A woman admitted to the emergency department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, “I am here with you, dear. Nothing can keep us apart.” What is the priority nursing intervention?
A. Ask the hospital security to remove the husband from the treatment room.
B. Notify the local police of suspected spousal abuse situation.
C. Reassure the husband that his wife will be treated well while he is in the waiting area.
D. Require the husband to leave the cubicle while the client is being treated.
*D
At the first meeting of a group of older adults at a daycare Center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, “You tell me, you're the leader.” What is the best response for the nurse to make?
A. I have been assigned to be the leader of this group. I will be here for the next six weeks.
B. I am the leader. You seem angry about not being the leader yourself.
C. I will be leading this group. What would you like to accomplish during this time?
D. I am the leader today. Would you like to be the leader tomorrow?
*C
And adolescent female client is admitted to the emergency department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room period what action should the nurse implement?
A. Sure the client that the male UAP is a staff member who wants to help her.
B. Asked her mother to please stay with her throughout the assessment procedures.
C. Tell the client that her fear is understandable under these circumstances.
D. Reassign an all-female health care team to the client until her fear subsides.
*D
A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, “Don't touch me! You're so stupid that you'll make it worse!” Which intervention is best for the nurse to implement?
A. Leave the room without saying a word.
B. Explain the health care providers prescription.
C. Allow the client to change the dressing himself.
D. Provide information about infection prevention.
*D
A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement?
A. Inform the health care provider and document the plan in the record.
B. Immediately contact the client spouse and the lover.
C. Keep this information confidential until the client's release.
D. File oral and written reports with the local Police Department.
*A
A client is pacing in the hall near the nurses’ station and swearing loudly. What response is best for the nurse to provide?
A. Please go to your room to get control of yourself.
B. Others are being distracted. Please, quiet down.
C. You seem pretty upset. Tell me about it.
D. Hey, what's going on?
*C
An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting?
A. Acrophobia
B. Agoraphobia
C. Claustrophobia
D. Post-traumatic stress disorder
*B
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were placed in his head for military surveillance of his every move. Which response is best for the nurse to provide?
A. It must be difficult for you to control your anxious feelings.
B. Go to occupational therapy and start a project.
C. You are in the hospital, and I am the nurse caring for you.
D. You are not in a war area now, this is the United States.
*B
During a one to one interaction, a mail client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing?
A. Self-Awareness
B. Focusing
C. Reflection
D. Clarification
*A
Which client should the nurse identify as the highest risk for the onset of stress-related problems?
A. A client who is passed over for promotion, quits a job to start a new business, and states, “This is just one of a series of challenges I’ve faced in my life.”
B. A woman who is graduating from college, getting married in one month, and states, “I’m anticipating the changes these events will make in my life.”
C. A person whose father died three months ago, who is losing a job due to company downsizing, and states, “Living with loss and the threat of loss makes me feel helpless.”
D. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, “I think I’m in control of my destiny.”
*C
On admission, a client who is highly anxious describes a delusion. The nurse understands that delusions are most likely to occur with which class of disorder?
A. Psychotic
B. Personality
C. Neurotic
D. Anxiety [Show Less]