Psych test B.
A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?
The client reports a sore throat.
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?
"If you do my homework for me, I won't bother you for the rest of the day."
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?
"Let's talk about what is upsetting you."
A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching?
"Administer the last dose of medication to your child 6 hours before bedtime."
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
"I am able to go to work every day, so I don't have a problem."
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?
"I feel so empty without my wife that it's hard to get up every morning."
A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?
"I will not take charge of my partner's work responsibilities."
A nurse is teaching the parents of a client about their daughter's diagnosis of bulimia nervosa. Which of the following statements made by the parents indicates an understanding of their daughter's illness?
"It is important for our daughter to have regular dental checkups.
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?
"It is not uncommon to feel angry toward yourself or others."
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse?
"Succinylcholine is given to reduce muscle movements during therapy."
A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching?
"Take this medication with food."
A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has a history of depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first?
"What medications are you currently taking?"
A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?
"You may experience difficulties with sexual functioning while taking this medication."
A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? (Select all that apply.)
-A client who is suicidal and in need of rapid treatment -A client who has bipolar disorder with rapid cycling -A client who has mania and has not responded to medication therapy
A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
A 35-year-old client who has major depressive disorder
A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs?
A client who has severe Alzheimer's disease
A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who is experiencing delusions of persecution
A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse?
A family where one or both parents witnessed intimate partner violence in the home as children
A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects
Acute dystonia
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?
Aggression toward animals
A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?
An older adult client who is bedbound and has a stage IV pressure ulcer
A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take?
Ask the client what the voices are saying.
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take?
Ask the family member if she has any thoughts or questions about the treatment plan.
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?
Clang association
A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement?
Discuss spiritual issues in a conversational manner.
A nurse in a provider's office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider?
Dark urine
A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first?
Discuss the importance of hair with the client.
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?
Do not administer the lorazepam.
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?
Gather supplies for endotracheal intubation.
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?
Hypertension
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?
Identify signs of escalation of violence.
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan?
Identify the client's trigger foods.
A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?
Inability to sleep
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?
Increased creatine phosphokinase (CPK)
A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?
Inform the client that her admission is confidential.
A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post traumatic stress disorder (PTSD)?
Lack of interest in an upcoming holiday
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?
Language delay
A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?
Nonmaleficence
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?
Orthostatic hypotension
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?
Permit the client to perform daily rituals to decrease anxiety.
A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse?
Provide frequent high-calorie snacks.
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
Rhinorrhea
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?
Set realistic limits on the client's behavior.
A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.)
Sodium level 125 mEq/L
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?
Substance use disorder
A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?
The client reports a sore throat
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for her deceased partner. Which of the following actions should the nurse take?
Talk with the client about activities she enjoyed with her partner.
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following nursing interventions assists in orienting the client to reality?
Talk with the client about scheduled daily activities.
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?
The client will refrain from self-mutilation.
A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication?
Urinary retention
