NUR136 EXAM 2
A nurse is interviewing a 25 year old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A. wide fluctuations in mood B. report of a minimum of five clinical findings of depression C. presence of manifestations for at least 2 years D. inflated sense of self-esteem
C
A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? A. borderline personality disorder B. acute withdrawal related to a substance use disorder C. bipolar disorder with rapid cycling D. dysphoric disorder
C
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "this medication increase the release of serotonin and norepinephrine" B. "I will need to monitor the client for hyponatremia while taking this medication" C. "this medication is contraindicated for clients who have an eating disorder" D. "sexual dysfunction is a common adverse effect of this medication"
A
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "tell me about how you are feeling right now" B. "you should focus on the positive things in your life to decrease your anxiety" C. "why do you believe you are experiencing this anxiety?" D. "let's discuss the medications your provider is prescribing to decrease your anxiety"
A
A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. administer the next dose of lithium carbonate as scheduled B. prepare for administration of aminophylline C. notify the provider for a possible increase in the dosage of lithium carbonate D. request a stat repeat of the client's lithium blood level
A
A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "you sound angry. anger is a normal feeling associated with loss" B. "I think you would feel better I you talked about your feelings with a support group" C. "I understand just how you feel. I felt the same when my mother died" D. "do other members of your family also feel this way?"
A
A nurse is communicating with a client who was just admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. offering advice B. reflecting C. listening attentively D. giving information
A
A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. creatinine and BUN C. WBC and granulocyte counts D. serum sodium and potassium
A
A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. assessing the client's risk for self-harm B. instilling hope for positive outcomes C. encouraging the client to participate in group therapy sessions D. encouraging the client to participate in treatment decisions
A
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? A. discussing ways to use new behaviors B. practicing new problem-solving skills C. developing goals D. establishing boundaries
A
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion? A. excessive stressors cause the client to experience distress B. the body's initial adaptive response to stress is denial C. absence of stressors results in homeostasis D. negative, rather than positive, stressors produce a biological response
A
A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. death of a chid 2 months ago B. recent weight loss of 30 lb C. retirement 1 year ago D. history of migraine headaches
A
A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? A. "cognitive reframing will help me change my irrational thoughts to something positive" B. "progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" C. "biofeedback causes my body to release endorphins so that I feel less stress and anxiety" D. "mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety"
A
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. placing the client on a one-to-one observation B. assisting the client to perform ADLs C. encouraging the client to participate in counseling D. teaching the client about medication adverse effects
A
A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (select all that apply) A. "I may experience feelings of resentment" B. "I will probably withdraw from others" C. "I can expect to experience changes in sleep" D. "it is possible that I will experience suicidal. thoughts" E. "It is expected that I will have a loss of self-esteem"
ABC
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (select all that apply) A. obsessive thoughts about disease B. history of childhood abuse C. avoidance of health care providers D. depressive disorder E. narcissistic personality
ABCD
A nurse working in an acute mental health facility is caring for a 35 year old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (select all that apply) A. age B. gender C. history of chronic asthma D. smoking E. being married
ABCD
A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (select all that apply) A. educational groups B. medication dispensing programs C. individual counseling programs D. detoxification programs E. family therapy
ABCE
A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (select all that apply) A. interpersonal relationships B. culture C. birth order D. religious beliefs E. prior experience with loss
ABDE
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "the voices won't leave me alone!" Which of the following statements should the nurse make? (select all that apply) A. "when did you start hearing the voices?" B. "the voices are not real, or else we would both hear them" C. "it must be scary to hear voices" D. "are the voices telling you to hurt yourself?" E. "why are the voices talking to only you?"
ACD
A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (select all that apply) A. concurrent administration of buspirone B. administration of a different SSRI C. use of a mouth guard D. changing to a different class of anti anxiety medication E. increasing the dose of paroxetine
ACD
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (select all that apply) A. auditory hallucination B. lack of motivation C. use of clang associations D. delusion of persecution E. constantly waving arms F. flat affect
ACDE
A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (select all that apply) A. "my family will be better off if I'm dead" B. "the stress in my life is too much to handle" C. "I wish my life was over" D. "I don't feel like I can ever be happy again" E. "if I kill myself then my problems will go away"
ACE
A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (select all that apply) A. conducting a suicide risk screening on all new clients B. creating a support group for family members of clients who completed suicide C. educating high school teens about suicide prevention D. initiating one-on-one observation for a client who has current suicidal ideation E. teaching middle-school educators about warning indicators of suicide
ACE
A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. void just before taking the medication B. increase the dietary intake of potassium C. wear sunglasses when outside D. change positions slowly when getting up E. chew sugarless gum
ACE
A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (select all that apply) A. difficulty concentrating on tasks B. obsessive need to talk about the traumatic event C. negative self-image D. recurring nightmares E. diminished reflexes
ACE
A home health nurse is making a visit to a client who has alzheimers disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? (select all that apply) A. install childproof door locks B. place rugs over electrical cords C. mark cleaning supplies with colored tape D. place the client's mattress on the floor E. install light fixtures above stairs
ADE
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (select all that apply) A. excessive worry for 6 months B. impulsive decision making C. delayed reflexes D. restlessness E. need for reassurance
ADE
A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (select all that apply) A. voice changes B. seizure activity C. disorientation D. dysphagia E. neck pain
ADE
A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. learn to practice mindfulness B. use assertiveness techniques C. exercise regularly D. rely on the support of a close friend
B
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. invasion of privacy B. false imprisonment C. assault D. battery
B
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. notify the nurse manager B. tell the nurse to stop discussing the behavior C. provide an in-service program about confidentiality D. complete an incident report
B
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following actions should the nurse take first? A. use therapeutic communication to discuss the hallucination with the client B. initiate one-to-one observation of the client C. focus the client on reality D. notify the provider of the client's statement
B
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you" C. "I can request that your case manager discuss appropriate charity options with you" D. "you should know that giving away your money is inappropriate"
B
A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "you should avoid taking over-the-counter acetaminophen while on donepezil" B. "you can expect the progression of cognitive decline to slow with donepezil" C. "you will be screened for underlying kidney disease prior to starting donepezil" D. "you should stop taking donepezil if you experience nausea or diarrhea"
B
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal" B. "I am no one, and everyone is me" C. "I feel monsters pinching me all over" D. "I know that you are stealing my thoughts"
B
A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "that is a good choice. ibuprofen does not interact with lithium" B. "regular aspirin would be a better choice than ibuprofen" C. "lithium decreases the effectiveness of ibuprofen" D. "the ibuprofen will make your lithium level fall too low"
B
A nurse is caring for a client who smokes and has lung cancer. The client reports "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. reaction formation B. denial C. displacement D. sublimination
B
A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. client's educational and economic background B. lethality of the method and availability of means C. quality of the client's social support D. client's insight into the reasons for the decision
B
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for a referral to an assertive community treatment (ACT) group? A. a client in an acute care mental health facility who has fallen several times while running down the hallway B. a client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia C. a client in a day treatment program who says he is becoming more anxious during group therapy D. a client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
B
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. the client asks the nurse whether she will go out to dinner with him B. the client accuses the nurse of telling him what to do just like his ex-girlfriend C. the client reminds the nurse of a friend who died from a substance overdose D. the client becomes angry and threatens harm to himself
B
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client, has a respiratory rate 30/min, and says, "this is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. mild B. moderate C. severe D. panic
B
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "while taking this medication, I'll need to stay out of the sun to avoid a skin rash" B. "I may feel drowsy for a few weeks after starting this medication" C. "I cannot eat my favorite pizza with pepperoni while taking this medication" D. "this medication will help me lose the weight that I have gained over the last year"
B
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. stop the interview at this point, and resume later when the client is better able to concentrate B. ask the client, "are you seeing something on the ceiling?" C. tell the client, "you seem to be looking at something on the ceiling. I see something there, too" D. continue the interview without comment on the client's behavior
B
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority? A. administer flumazenil B. identify the client's level of orientation C. infuse IV fluids D. prepare the client for gastric lavage
B
A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (select all that apply) A. age older than 65 years B. anxiety disorder C. female gender D. coronary artery disease E. obesity
BC
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply) A. "client ate most of his breakfast" B. "client was offered 8 oz of water every hour" C. "client shouted obscenities at assistive personnel" D. client received chlorpromazine 15 mg by mouth at 1000" E. "client acted out after lunch"
BCD
A charge nurse is reviewing kubler-ross: five stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (select all that apply) A. disequilibrium B. denial C. bargaining D. anger E. depression
BCDE
A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (select all that apply) A. decreased level of consciousness B. drooling C. involuntary arm movements D. urinary retention E. continual pacing
BCE
A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (select all that apply) A. chronic pain B. depressed immune system C. increased blood pressure D. panic attacks E. unhappiness
BCE
A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (select all that apply) A. avoid thinking about the incident when it is over B. take breaks during the incident for food and water C. debrief with others following the incident D. hold emotions in check in the days following the incident E. take advantage of offered counseling
BCE
A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (select all that apply) A. history of gradual memory loss B. family report of personality changes C. hallucinations D. unaltered level of consciousness E. restlessness
BCE
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (select all that apply) A. provide flexible client behavior expectations B. offer concise explanations C. establish consistent limits D. disregard client complaints E. use a firm approach with communication
BCE
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (select all that apply) A. reassure the client that everything will be okay B. discuss prior use of coping mechanisms with the client C. ignore the client's anxiety so that she will not be embarrassed D. demonstrate a calm manner while using simple and clear directions E. gather information from the client using closed-ended questions
BD
A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse monitor? (select all that apply) A. elevated blood glucose level B. orthostatic hypotension C. priapism D. headache E. bruxism
BD
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (select all that apply) A. hypothermia B. hallucinations C. muscular flaccidity D. diaphoresis E. agitation
BDE
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (select all that apply) A. use caffeine in moderation to prevent relapse B. difficulty sleeping can indicate a relapse C. begin taking your medications as soon as a relapse begins D. participating in psychotherapy can help prevent a relapse E. anhedonia is a clinical manifestation of a depressive relapse
BDE
A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "care during the continuation phase focuses on treating continued manifestations of MDD" B. "the treatment of MDD during the maintenance phase lasts for 6 to 12 weeks" C. "the client is at greatest risk for suicide during the first weeks of an MDD episode" D. "medication and psychotherapy are most effective during the acute phase of MDD"
C
A client tells a nurse, "don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife B. keep the client's communication confidential, but watch the client and his roommate closely C. tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. report the incident to the health care team, but do not inform the client of the intention to do so
C
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? A. educating clients on health promotion techniques to reduce the risk of depression B. performing screenings for depression at community health programs C. establishing rehabilitation programs to decrease the effects of depression D. providing support groups for clients at risk for depression
C
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care? A. receiving daily care from a home health aide B. having a weekly visit from a nurse case worker C. attending a partial hospitalization program D. visiting a community mental health center on a daily basis
C
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. a client who has schizophrenia with delusions of grandeur B. a client who has manifestations of depression and attempted suicide a year ago C. a client who has borderline personality disorder and assaulted a homeless man with a metal rod D. a client who has bipolar disorder and paces quickly around the room while talking to himself
C
A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. the nurse discusses the client's weight loss during a health care team meeting B. the nurse examines her own personal feelings about clients who have anorexia nervosa C. the nurse asks the client about her body image perception D. the nurse presents an educational session about anorexia nervosa to a large group of adolescents
C
A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. the client explains that her body seems to be floating above the ground B. the client has the idea that someone is trying to kill her and steal her money C. the client states that the furniture in the room seems to be small and far away D. the client cannot recall anything that happened during the past 2 weeks
C
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications? A. chlorpromazine B. thiothixene C. risperidone D. haloperidol
C
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalize anxiety disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime" B. "I will follow a low-sodium diet while taking this medication" C. "I will need to discontinue this medication slowly" D. "I will be at risk for weight loss with long-term use of this medication"
C
A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first? A. a client who recently burned her arm while using a hot iron at home B. a client who request that her antipsychotic medication be changed due to some new adverse effects C. a client who says he is hearing a voice that tells him he is not worthy of living anymore D. a client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview
C
A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect? A. "I had to pretend I was injured in order to get disability benefits" B. "I know that my abdominal pain is caused by a malignant tumor" C. "I needed to make my son sick so that someone else would take care of him for a while" D. "I became deaf when I heard that my husband was having an affair with my best friend"
C
A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. verify that a current power of attorney document is on file B. instruct the client's partner to offer finger foods to increase oral intake C. provide information on resources for respite care D. schedule the client for placement of an enteral feeding tube
C
A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? A. "you and a group of other clients will meet to discuss your treatment plans" B. "community meetings have a specific agenda that is established by staff" C. "you and the other clients will meet with staff to discuss common problems" D. "community meetings are an excellent opportunity to explore your personal mental health issues"
C
A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the teaching? A. "I will be able to stop taking this medication as soon as I feel better" B. "If I feel drowsy during the day, I will stop taking this medication and call my provider" C. "I will be careful not to gain too much weight while taking this medication" D. "this medication is highly addictive and must be withdrawn slowly"
C
A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. the client has a family history of seasonal pattern depression B. the client currently smokes 1.5 packs of cigarettes per day C. the client had a motor vehicle crash last year and sustained a head injury D. the client has a BMI of 25 and has gained 10 lb over the last year
C
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? A. "I feel very sorry for the loneliness you must be experiencing" B. "suicide is not the appropriate way to cope with loss" C. "losing someone close to you must be very upsetting" D. "I know how difficult it is to lose a loved one"
C
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly license nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder" B. "ECT is contraindicated for clients who have suicidal ideation" C. "ECT is effective for clients who are experiencing severe mania" D. "ECT is prescribed to prevent relapse of bipolar disorder"
C
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. narcissistic behavior B. fear of rejection from staff C. attempt to reduce anxiety D. adverse effet of antidepressant medication
C
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating" B. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD" C. "I am aware that my PMDD causes me to have rapid mood swings" D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active"
C
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (select all that apply) A. the needs of both participants are met B. an emotional commitment exists between the participants C. it is goal-directed D. behavioral change is encouraged E. a termination date is established
CDE
A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (select all that apply) A. hypotension B. paralytic ileus C. memory loss D. nausea E. confusion
CDE
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (select all that apply) A. olanzapine B. quetiapine C. aripiprazole D. clozapine E. asenapine
CDE
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. personal space B. posture C. eye contact D. intonation
D
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "TMS is indicated for clients who have schizophrenia spectrum disorders" B. "I will provide post anesthesia care following TMS" C. "TMS treatments usually last 5 to 10 minutes" D. "I will schedule the client for daily TMS treatments for the first several weeks"
D
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics? (select all that apply) A. auditory hallucinations B. withdrawal from social situations C. delusions of grandeur D. severe agitation E anhedonia
D
A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "you have forgotten that this is your home" B. "you cannot go outside without a staff member" C. "why would you want to leave? aren't you happy with your care?" D. "I am your nurse. let's walk together to your room."
D
A nurse in an acute mental health facility is caring for client who has bipolar disorder. Which of the following is the priority nursing action? A. set consistent limits for expected client behavior B. administer prescribed medications as scheduled C. provide the client with step-by-step instructions during hygiene activities D. monitor the client for escalating behavior
D
A nurse in an acute mental health facility is communication with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "you are having difficulty sleeping?" which of the following therapeutic communication techniques is the nurse demonstrating? A. offering general leads B. summarizing C. focusing D. restating
D
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? A. teach the client to recognize how stress brings on a personality change in the client B. repeatedly present the client with information about past events C. make decisions for the client regarding routine daily activities D. work with the client on grounding techniques
D
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report to the provider? A. "my mother has diabetes that is controlled by her diet" B. "my mother recently completed a course of prednisone for acute bronchitis" C. "my mother received her flu vaccine last month" D. "my mother is currently on furosemide for her congestive heart failure"
D
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. discuss new relaxation techniques B. show the client how to change his behavior C. distract the client with a television show D. stay with the client and remain quiet
D
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. assign the client to a private room B. document the client's behavior every hour C. allow the client to keep perfume in her room D. ensure that the client swallows medication
D
A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding? A. "you really should complete your own work. I don't think it's right to expect me to complete your responsibilities" B. "why do you expect me to finish your work? you must realize that I have my own responsibilities" C. "it is not fair to expect me to complete your work. if you continue, then I will report your behavior to our supervisor" D. "when I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities"
D
A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I think your son is getting better. What have you noticed? B. "I'm sure everything will be okay. It just takes time to heal" C. "I'm not sure what's wrong. Have you asks the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically"
D
A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect? A. the client remembers many details about the traumatic incident B. the client expresses heightened elation about what is happening C. the client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred D. the client expresses a sense of unreality about the traumatic incident
D
A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. a client's verbal threat of suicide is attention-seeking behavior B. interventions are ineffective for clients who really want to commit suicide C. using the term suicide increases the client's risk for a suicide attempt D. a no-suicide contract decreases the client's risk for suicide
D
A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. encourage the client to spend time alone in his room B. monitor the client for self-harm once per day C. allow the client unlimited time to discuss physical manifestations D. discuss alternative coping strategies with the client
D
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "it is common to treat depression with ECT before trying medications" B. "I can have my depression cured if I receive a series of ECT treatments" C. "I should receive ECT once a week for 6 weeks" D. "I will receive a muscle relaxant to protect me from injury during ECT"
D
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide? A. three to six weeks of treatment is required to achieve therapeutic benefit B. combining alcohol with diazepam will produce a paradoxical response C. diazepam has a lower risk for dependence than other anti anxiety medications D. report confusion as a potential indication of toxicity
D
