26- The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to
... [Show More] concentrate. The nurse has only 15 min to talk with the client. To develop a treatment plan for this client, wich assessment is most important for the nurse to obtain?
A) Motivation for treatment
B) History of substance use
C) Medication compliance
D) Mental status examination
27- A client who is known to abuse drugs is admitted to the psychiatric unit. With medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
A) Diphenhydramine (Benadryl)
B) Perphenazine (trilafon)
C) Isocarboxazid (marplan)
D) Clordiazepoxide (Librium)
28- A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several
days. Which priority nursing problem should the nurse couinclude in this client’s plan of care?
A) Risk for suicide
B) Sleep deprivation
C) Situational low self-esteem.
D) Social isolation.
29- A woman brings her 48- years –old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She state that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with:
A) Post-traumatic stress syndrome.
B) Panic disorder.
C) Dissociative disorder.
D) Obsessive-compulsive disorder.
30- A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102. Pulse rate is 110b/min, and his blood alcohol level (BAL)is 0 mg/dl. Which prescription should the nurse administer?
A) Haloperidol (Haldol) B) Thiamine (Vit B1) C) Diphenhydramine (Benadryl)
D)
Lorazepan (Ativan)
31- The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client’s room in the morning and finds the what intervention is best for the nurse to implement?
A) Assist the client to get out bed and involved in an activity.
B) Monitor the client’s appetite and pattern of sleep.
C) Assess the client’s feelings about the hospital stay.
D) Explain that staff will check on the client every 30 min
32- A client who refuse antipsychotic medications disrupts group activities, talks with nonsensical words wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment findings?
A) Wanders into client’s rooms.
B) Refuse antipsychotic medication.
C) Talks with nonsensical words.
D) Disrupts group activities.
33- Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
A) I am here because the police thought I was doing something wrong”
B) I want to be here because I know it is the best psychiatric facility”
C) At least I hit the wall instead of hitting the psychiatric aide”
D) Don’t believe everything my family tells you, I am not crazy”
34- A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?
A) Let’s go ask another nurse if this true.”
B) My name tag shows that I am a nurse here.”
C) I cannot possibly be one of your children”
D) I know that you don’t have 9 children”
35- A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
A) Encourage the client to exercise
B) Suggest that the client to develop a list of pleasurable activities
C) Teach the client to develop a plan for daily structured activities
D) Provide education on methods to enhance sleep
36- A high school girl reveals to the school nurse that she has been engaging in self-induced vomiting as a weight-control measure. Which initial assessment should the nurse 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.
37- A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
A) Excessive CNS stimulation will be reduce
B) Co- dependent behaviors will be decreased
C) Client’s level of consciousness will increase.
D) Client will not demonstrate cross- addiction
38- A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside , looking for a red one to sit in. when another client objects the disturbance, the client shouts, “I am the boss here. I do what I want” which nursing problem best supports these observation?
A) Deficient diversional activity related to excess energy level
B) Disturbed personal identity related to grandiosity
C) Risk for activity intolerance related to hyperactivity
D) Risk for other related violence related to disruptive behaviors
39- Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (vicodin). Within 15 min 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
40- Following surgery, a male client with antisocial personality disorder frequently request that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?
A) Reassure the client that his request will be met whenever possible
B) Advise the client that assignments are not based on client requests
C) Ask the client to explain why he constantly request the nurse
D) Encourage the client to verbalize his feelings about the nurse
41- A client postpartum depression receives prescription for sertraline (Zoloft). What information is most important to include in client teaching?
A) Avoid processed meats, red, wine, and Swiss cheese
B) Contact the healthcare provider immediately if suicidal thoughts occur.
C) Increase activity level to include a daily exercise routine
D) Contact the healthcare provider immediately if muscle stiffness
42- When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually takes a different dosage. What action should the nurse 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 take it
D) Explain to the client that the dosage has been changed
43- A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting and drowsiness. What action should the nurse take?
A) Notify de healthcare provider immediately and prepare for admon of an antidote
B) Hold the medication and refuse to admon additional [Show Less]