Test 5 MedSurg 2
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following is the highest priority? A. Protecting the client from injury B. Determining the cause of the client's anxiety C. Ensuring that the client feels safe D. Identifying the client's coping skills.
A.
A nurse in an inpatient mental health unit is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? A. Home environments B. Support systems C. Suicide risk D. Psychiatric history
C.
A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask? a. "What will you accomplish by taking your life?" b. "What happened to you in the past to make you so desperate?" c. "How will you carry out your plan?" d. "Why do you feel depressed enough to end your life?"
C.
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? A. Confront the client for breaking the rules B. Stand close to the client to offer comfort and support C. Speak to the client with clear, calm, caring statements D. Escort the client to the nurse's station
C.
A nurse overhears a client with schizophrenia talking to herself. The client keeps stating, "The mazukas are coming. The mazukas are coming." The nurse correctly recognizes the use of the word "mazuka" as an example of which of the following alterations in speech? A. Echolalia B. Clang association C. Neologism D. Word salad
C.
The nurse is caring for a client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse use to handle the client's ritualistic behaviors? A. Isolate the client for a period of time. B. Confront the client about the senseless nature of the ritualistic behaviors. C. Plan the client's schedule to allow time for rituals. D. Set strict limits on the behaviors so the client can conform to the unit rules and schedules.
C.
Which characteristic of the abuser should the nurse look for when completing the family assessment of a victim of intimate partner violence? A. Encourages the partner to have a life outside the intimate relationship B. An inflated sense of self-esteem C. Needy and possessive of the partner D. An ability to feel remorse for the abuse
C.
Which of the following is the most common behavioral finding among clients who have depression? A. Focus on past failures B. Slowed body movement C. Lack of energy D. Sleep disturbances.
C.
Which of the following statements by a client with mood disorder indicates readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always have my mother to help me. C. I will take my medicines as I should, and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything.
C.
What assessing for anorexia nervosa, the nurse would anticipate finding which of the following characteristics?. (select all that apply)
Good academics Teenage girl
What is an adverse effect of Alprazolam (Xanax)?
Impaired memory
What does the client use when he blames others for unacceptable thoughts and feelings.
Projection
What supplement is used to treat mild to moderate depression and to relieve depression related to anxiety?
St. Johns Wort
A nurse is caring for a client whose adolescent child died in a motor-vehicle crash. The client is crying inconsolably. Which action should the nurse take?
Stay with the client and allow the client to cry.
A nurse is assisting a client who has multiple injuries from a motor vehicle crash as a result of driving under he influence of alcohol. The client tells the nurse, "I had a few drinks after my boss fired me, but that okay. Everything will work out somehow next week". Which of the following defense mechanisms is the client demonstrating?
Suppression/ Denial
A nurse is caring for a patient who has been on SSRI for depression for the last three months without improvement. The provider is planning on changing the patient to an MAOI. In regard to the two medications, which of the following factors should the nurse take into consideration?
The SSRI must be discontinued for 5 weeks before starting the MAOI to prevent serotonin syndrome.
The nurse provides care for a client diagnosed with paranoid schizophrenia. The client tells the nurse, "There are really strange people in the corner laughing and saying bad things about me." Which response by the nurse is best?
"That sounds frightening. There is no one in the corner."
Which client outcome provides reassurance that the therapeutic regimen managing the client with schizophrenia is appropriate? (select all that apply) A. The client understands the medical management B. The client can discuss the mental health condition C. The client has been able to become an upstanding member of society D. The client reports decrease in hallucinations and delusions. E. The client remains in the home and relies on other for daily activities.
A, B, C, D
A client is being evaluated for an eating disorder. Which nursing assessment finding is most indicative of a client with bulimia nervosa? (select all that apply) A. Overweight or normal weight B. Admits to purging and binging C. Obsessed with thinness D. Eroded teeth enamel E. Distorted body image
A, B, D
The nurse is providing discharge instructions to the client being prescribed antipsychotic medications. Which discharge instruction will be included? (select all that apply) A. Talk to the physician before purchasing herbal medications B. Notify the physician if you have hypertension or severe muscle stiffness C. Abruptly stop medication D. Take all antipsychotic medications as directed E. Double the dose
A, B, D
The nurse is completing a plan of care for a client on lithium therapy to manage bipolar symptoms. Which nursing interventions will be included? (Select all that apply) A. Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination. B. Increase fluid intake to 3000 mL/day. C. Limit sodium intake daily. D. Monitor kidney and liver functioning. E. Instruct client that it may take up to 6 weeks to reach therapeutic level. F. Monitor intake and output.
A, B, D, F
Which assessment finding places the elderly at greater risk for the development of alcohol dependency? (select all that apply) A. Recent spousal loss B. History of Gastritis C. Chronic pain D. Impaired memory E. Income
A, C
Which of the following assessment findings are most important in determining the presence of alcohol dependency in a client? (select all that apply) A. Blackouts B. Blurred Vision C. Patterns of use D. Absenteeism from work E. Weight loss
A, C, D
The nurse is admitting a client into a mental health facility and completing a mental status examination. Which assessment criteria would the nurse document to complete a total score? Select all that apply. A. Thought content B. Family report C. Physical appearance D. Attention E. History of abuse F. Memory
A, C, D, F
A client with a paranoid disorder refuses to eat because he believes that the food being served in the mental health unit is poisoned. Which response is an appropriate way for the nurse to defuse the client's delusional thoughts? A. Providing the client with food items in sealed containers B. Telling the client that he is safe now that he is in the hospital C. Setting firm limits and telling the client that the food is not poisoned D. Asking the client whether he would like to visit the hospital kitchen to watch the food being prepared
A.
A depressed patient is threatening to harm himself. Which nursing action indicates an understanding of the appropriate care of the suicidal patient? A. The nurse asks the patient if he has a plan. B. The nurse calls the family and asks them to visit the patient. C. The nurse administers a sedative. D. The nurse places the patient in seclusion.
A.
A male patient admitted with acute mania tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, "I am the only one he trusts, because I am the best!" For documentation purposes what is this behavior referred to as? A. Grandiosity B. Rapid cycling C. Flight of ideas D. Unpredictability
A.
A nurse assesses a client and determines that the client is experiencing mild anxiety based on which of the following? a) Selectively inattentive b) Aware and alert c) Focused attention on a small area d) Feelings of unreality
A.
A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. she tells the nurse " i know my eating binges and vomiting are not normal, but i cannot do anything about them" which of the following is therapeutic response by the nurse? A. It seems like you are feeling helpless about this behavior B. Do you have any idea why you do this C. I'm proud of you for recognizing that this behavior is not normal D. You should stop because you need to. you are destroying your health
A.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following behaviors that may cause lithium toxicity? A. Fasting B. Drinking caffeine C. Exercising moderately D. Drinking water
A.
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention? a. Determine the presence and degree of suicidal risk b. Assist the client to identify negative effects of chemical dependency c. Identify support groups in the community for long-term treatment d. Refer the client to a mental health care provider for evaluation and treatment
A.
A nurse is caring for a client who has schizophrenia and is experiencing auditory and visual hallucinations. Which of the following actions should the nurse take? A. Ask the client what the voices are saying B. Encourage the client to use reality testing C. Limit the client's exposure to noise D. Place the client in seclusion
A.
A nurse is caring for a client who is withdrawing from opioid addiction. Which of the following medications should be included in client care? A. methadone B. Disulfiram C.Risperidone D. Lithium Carbonate
A.
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements by the nurse is appropriate? A. "you said that you feel guilty about your daughter's diagnosis. let's talk about what is causing you to feel this way" B. "you should not feel guilty about your daughter's diagnosis. schizophrenia is unpreventable" C. "i'm sure your daughter's diagnosis is very difficult to deal with, but everything will be alright once she receives the proper treatment" D. "your provider has explained the causes of schizophrenia. why do you feel guilty about your daughter's diagnosis?"
A.
A nurse is observing a client who has histrionic personality disorder. Which of the following behaviors should the nurse expect? A. The client whispers in the provider's ear B. The client refuses to provide her telephone number C. The client has diminished facial expressions D. The client asks if she is doing the right thing 3 times during the appointment
A.
A nurse is reviewing the lab reports of a client who has bipolar disorder and notes a serum lithium level of 2.0. Which of the following actions should the nurse take? A. Determine vital signs B. Continue to monitor the client q2h C. Decrease the client's fluid intake D. Request the laboratory repeat the test the next morning.
A.
The client also begins an atypical antipsychotic, risperidone, because she reports hearing a "scary voice" upon admission. Although the client remains very withdrawn and noncommunicative, the nurse must explain the purpose of risperidone. Which explanation is best? A. risperidone will help the client think more clearly B. risperidone will help the client sleep better C. risperidone will help the client control impulsive feelings D. risperidone will enhance the effectiveness of the antidepressant
A.
The client with depression who is taking imipramine states to the nurse, "My health care provider (HCP) wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine." Which response by the nurse is most appropriate? A. "It's routine practice to have an ECG periodically because there is a slight chance that the drug may affect the heart." B. "It's probably a precautionary measure because I'm not aware that you have a cardiac condition." C. "Try not to worry too much about this. Your health care provider (HCP) is just being very thorough in monitoring your condition." D."You had an ECG before you were prescribed imipramine, and the procedure will be the same."
A.
The client with depressive disorder, is in alcohol withdrawal and reports a recent job loss. Which of the following should be the priority nursing intervention? A. Determine the presence and degree of suicidal risk. B. Assist the client to identify negative effects of chemical dependency. C. Identify support groups in the community for long term treatment. D. Refer client to a mental health care provider for evaluation and treatment.
A.
The client with schizophrenia states he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? A. Command hallucination B. Gustatory hallucination C. Automatic obedience. D. Negativism
A.
Which of the following observations is helpful in determining a client's mood? (Select all that apply) A. Body language B. Speech C. Client appearance D. Energy level E. Work History
A., B, C, D
A client diagnosed with obsessive-compulsive disorder comes to the clinic with the client's spouse. During the visit, the spouse states, "The client is always checking and rechecking to make sure that all of the appliances are turned off before we go out. It's nerve-wracking. We can never get out of the house on time. Isn't checking once enough?" An understanding of what would the nurse need to incorporate into the response? A. The client is attempting to exert control over the situation. B. The client performs the ritual to relieve anxiety temporarily. C. The client's behavior reflects a need for safety. D. The client is attempting to use thought stopping to decrease the behavior.
B.
A client is being seen in the mental health clinic. The client has been on haloperidol for 8 months and is now exhibiting tongue protrusion, lip smacking, and rapid eye blinking. A nurse would document this chronic syndrome as: A. Dystonia. B. Tardive dyskinesia. C. Akathisia. D. Neuroleptic malignant syndrome (NMS).
B.
A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? A. Narcotic pain medication is contraindicated for all clients with active substance-use problems. B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
B.
A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of clients. The nurse should expect to administer methadone for a client who has a substance use disorder for which of the following substances? A. Amphetamines B. Opiates C. Barbiturates D. Hallucinogenics
B.
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I am coughing because I have a cold that everyone has been getting." The nurse should that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation
B.
A nurse is providing discharge teaching to a client with a new prescription for phenelzine. The nurse should instruct the client to avoid which of the following foods when taking this medication? A. Cottage cheese B. Salami C. Apple pie D. Grilled steak
B.
What should the nurse administer to a patient undergoing detoxification for alcohol to minimize the client's craving for alcohol during the process? A. Methadone B. Naltrexone C. Buprenorphine D. Disulfiram
B.
The peak age during which women develop anorexia nervosa is:
Between 14 and 18
A client who reports moderate to severe anxiety requires intervention. Which of the following teaching points would be helpful in assisting this client in the management of anxiety? (select all that apply) A. Using rapid respirations B. Taking cool shower or bath C. Visualizing a relaxing place D. Listen to music E. Smoke a cigarette F)Progressively tighten muscles
C, D
A client who has bipolar disorder approaches the nurse and reveals self-inflicted, superficial cuts going up and down to his right arm. Which of the following actions should the nurse take first? A. Implement the client's behavioral modification plan B. Document the size and location of the cuts C. Inspect the cuts for debris. D. Administer a tetanus antitoxin.
C.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? a. Recommend that the partner place the client in a long-term care facility b. Suggest that the partner see a counselor to help him cope with his exhaustion. c. Ask the partner to talk about his difficulties in caring for the client d. Tell the partner to call a family meeting to get help
C.
A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. These manifestations indicate which of the following adverse effects of haloperidol? A. Akathisia B. Acute dystonia C. Tardive dyskinesia D. Pseudoparkinsonism
C.
A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the electroconvulsive therapy (ECT) treatment scheduled for tomorrow?" Which of the following should be the nurse's response? a. "You have already given signed consent for the treatments after they were explained to you." b. "You will feel better after the course of treatments." c. "You have the right to refuse even though the consent form has been signed." d. "You can refuse them, but the provider may be upset with you."
C.
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription from the provider for which of the following medications? A. Chlorpromazine B. Thiothixene C. Risperidone D. Haloperidol
C.
A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as positive symptoms? A. Hallucinations B. Inability to experience pleasure C. Disorganized speech D. Unusual behavior
C.
A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has the legal right to refuse treatment? A. A 16 year old client whose parents have requested treatment B. An older adult client who has delusions and refuses treatment for religious reasons C. An older adult client who was voluntarily admitted D. A client who is competent but was involuntary admitted
C.
A nurse is collecting data from a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. "I thought I heard something too." B. "Is someone telling you something?" C. "What are you hearing?" D. "There is nobody in that chair for you to listen to."
C.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care? A. Allow manipulation so as to not raise the client's anxiety. B. Create a strict schedule for the client's activities to discourage manipulation. C. Institute consequences for manipulative behavior. D. Bargain with the client to discourage manipulative behavior.
C.
A nurse is providing teaching to a client who has alcohol use disorder about AA. Which of the following client statements indicates an understanding of the program's basic concepts? A. "I am responsible for my alcoholism." B. "I need to identify things that cause me to be an alcoholic." C. "I am powerless against my addiction to alcohol." D. "I need to see a counselor who will be responsible for my recovery."
C.
Which of the following supports the admitting diagnosis of acute mania in the client with bipolar disorder? A. The client spouse reports that the client has recently gained weight B. The client is dressed in all black C. Client responds to questions with disorganized speech D. The client reports that voices are telling him to write a novel
C.
Which of the following negative symptoms of schizophrenia defines "flat affect"? A. Inability to initiate and persist in activities B. Inability to experience pleasure C. Lack of emotional response, and a blank facial expression D. Lack of speech content and/or slowed speech response
C.
What is an appropriate action in response to verbal abuse?
Calmly removing herself from the situation
Quetiapine (Seroquel)- (Antipsychotic)
Commonly causes drowsiness, especially for the first week.
A client on lithium has suffered from diarrhea and vomiting. Which of the following is the priority nursing intervention of the nurse in-charge? A. Reassure the client that these are common side effects of lithium therapy B. Recognized this as a drug interaction C. Give the client Cogentin D. Hold the next dose and obtain an order for a stat serum lithium level
D.
A nurse in a mental health unit is preparing to discharge a client who has bulimia nervosa. Which of the medications should the nurse expect the provider to prescribe for the client? A. Paroxetine B. Fluconazole C. Bupropion D. Fluoxetine
D.
A nurse is caring for a client who has schizophrenia and has been admitted to the mental health unit. The client has a history of aggression and has been continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A. "It's a beautiful day outside. Let's take a walk together." B. "Sit down so we can try a relaxation exercise." C. "Would you like your anti-anxiety medication now?" D. "You are pacing back and forth. Can you tell me what you are feeling?"
D.
A nurse is caring for a client who is a resident in a facility designed for the care of clients with Alzheimer disease.The client has been oriented to name and place and is usually cooperative and able to perform activities of daily living (ADL) with minimal supervision. When the client refuses to take medications, the nurse should? A. notify the provider of the client's increasing confusion. B. crush the pills, if not contraindicated, and mix them in the client's applesauce. C. explain to the client the possible implications of missing a dose. D. ask the client to express the reasons for refusing the morning medications and document the event.
D.
A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client in maintaining sobriety? A. Varenicline B. Clonidine C. Buprenorphone D. Disulfiram
D.
A nurse is collecting data from a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal? A. Decreased appetite B. Slurred speech C. Insomnia D. Hallucinations
D.
A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for valproic acid. The nurse should explain that the provider will routinely prescribe which of the following tests while the client is taking valproic acid? A. Electrocardiogram B. Chest X-ray C. Thyroid function tests D. Liver function levels
D.
The client with anxiety has a prescription for alprazolam (Xanax) 0.25mg PO every 8 hr. PRN anxiety. Which of the following is an appropriate situation to administer alprazolam to this client? A. The client states, "I see purple bugs crawling on the wall." B. The client describes an increase in pain after receiving meperidine (Demerol). C. The client pretends to be a government agent. D. The client states, "My heart is pounding out of my chest."
D.
The client with obsessive compulsive disorder (OCD) is constantly picking up after others in the day room. The nurse recognizes the client uses this behavior to do which of the following? A. Limit the amount of time available to interact with others. B. Focus attention on meaningful tasks. C. Manipulate and control others' behaviors. D. Decrease anxiety to a tolerable level.
D.
What assumption can be made about the client who has been admitted on an involuntary basis? A. The client can be discharged from the unit on demand. B. For the first 48 hours, the client can be given medication over objection. C. The client has agreed to fully participate in treatment and care planning. D. The client is a danger to self or others or unable to meet basic needs.
D.
A nurse is providing discharge teaching for a client who has a new prescription for Quetiapine (Seroquel). Which of the following adverse effects should the nurse inform the client is associated with this medication?
Drowsiness
What is the first-line of treatment for clients who are experiencing an acute depressive episode of bipolar disorder?
Lithium Carbonate
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications. Findings include muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should recognize which of the following adverse effects may be occurring?
Neuroleptic malignant syndrome
One week ago, a 74-year-old was started on a benzodiazepine for the treatment of an anxiety disorder. The client comes into the clinic for a follow-up visit and states feeling nervous, is having trouble sleeping, and feels hyperactive. What does the nurse understand may be occurring as a result of this medication?
Paradoxical Excitement
Group therapy allow clients with mental illnesses the opportunity to enhance what?
Personal relationships, increase self-awareness, and try new behaviors.
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?
Potassium 2.8
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
Preparing for artificial ventilation.
