EXAM 3 NCLEX REVIEW PSYCH

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5. The nurse plans care based on which representation of this level? A. Toxic B. Normal C. Slightly above normal D. Excessively below normal

A. Toxic

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? 1. "Why don't you tell your wife about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."

2. "What do you find difficult about this situation?"

The nurse is administering risperidone to a client who is scheduled discharge. Before dc, which info should the nurse provide to the client? A. Get adequate sunlight B. Continue driving as usual C. Avoid foods rick in potassium D. Get up slowly when changing position

D. Get up slowly when changing position

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? A. Call the nursing supervisor B. Call security to block all exist areas C. Restrain the client until the health care provider (HCP) can be reached. D. Tell the client that the client cannot return to this hospital again if the client leaves now.

A. Call the nursing supervisor --> the client should be asked to wait to speak to the HCP before leaving and to sign AMA document before leaving. If the client refuses, the nurse cannot hold the client against the client's will and therefore in this situation she'd call the nurse supervisor.

Which nursing interventions are appropriate for a client hospitalized with mania who is exhibiting manipulative behavior? SA A. Communicate expected behaviors to the client B. Ensure that the client know that they are not in charge of the nursing unit C. Assist the client in identifying ways of setting limits on personal behaviors D. Follow through about the consequences of behavior in a non punitive manner E. Enforce rules by informing the pt that he/she will not be allowed to attend therapy groups F. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A. Communicate expected behaviors to the client C. Assist the client in identifying ways of setting limits on personal behaviors D. Follow through about the consequences of behavior in a non punitive manner F. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should access the results of which lab study to monitor for adverse effects from this medication? A. Plt count B. Blood glucose level C. LFTS D. WBC

D. WBC

A client is admitted with a recent hx of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? SA A. "I am afraid of spiders" B. "I keep reliving the robbery." C. "I see his face everywhere I go." D. "I don't want anything to eat now." E. "I might have died over a few dollars in my pocket." F. "I have to wash my hands over and over again many times."

B. "I keep reliving the robbery." C. "I see his face everywhere I go." E. "I might have died over a few dollars in my pocket."

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? SA A. initiate confinement measures B. Acknowledge the client's behavior C. Assist the client to an area that is quiet D. Maintain a safe distance from the client E. Allow the client to take control of the situation

B. Acknowledge the client's behavior C. Assist the client to an area that is quiet D. Maintain a safe distance from the client

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? A. Ask the client why he started taking illegal drugs B. Ask the client about the amt of drug use and its effect C. Ask the client how long he thought he could take drugs without someone finding out D. Not ask any questions

B. Ask the client about the amt of drug use and its effect

The police arrives at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? A. Admin an antianxiety agent B. Assess and treat the wound sites C. Secure and record a detailed hx D. Encourage and assist the client to ventilate feelings

B. Assess and treat the wound sites

A hospitalized client has been taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amt of med? A. Constipation B. Seizure activity C. Increased weight D. Dizziness when getting upset

B. Seizure activity

A nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? A. Increase socialization of the pt with peers B. Avoid using a whisper voice in front of the client C. Begin to educate the client about social supports in the community D. Have the client sign a release of info to appropriate parties for assessment purposes.

B. Avoid using a whisper voice in front of the client ( disturbed thought process is r/o paranoid personality disorder; pt is distrustful & suspicious of others; member of health care team need to est. rapport & trust with the client; laughing & whispering infront of the client would be counterproductive)

The nurse determines that the wife of an alcoholic client is benefiting from attending an A1-Anon group if the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beating my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

A. "I no longer feel that I deserve the beating my husband inflicts on me." --> healthiest response

A client is unwilling to go to his church because his ex-gf goes there and he feels that she will laugh at him if she sees him. Cuz of his hypersensitivity to a reaction from her, the Pt remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? A. Avoidant B. Bordline C. Schizotypal D. Obsessive - compulsive

A. Avoidant

The ER nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? A. Info regarding shelters B. Instructions regarding calling the police C. Instructions regarding self-defense classes D. Explaining the importance of leaving the violent situation

A. Info regarding shelters

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SA A. Monitor VS B. Provide safe environment C. Address hallucinations therapeutically D. Provide stimulation in the environment E. Provide reality orientation as appropriate F. Maintain NPO

A. Monitor VS B. Provide safe environment C. Address hallucinations therapeutically E. Provide reality orientation as appropriate

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A. One-to-one suicide precautions B. Suicide precautions with 30-min checks C. Checking the whereabouts of the client every 15 mins D. Asking the client to report suicidal thoughts immediately

A. One-to-one suicide precautions

The nurse observes that a client is pacing, agitated and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? A. Provide safety for the pt and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff in caring for the client in a controlled environment D. Offer the client a less stimulating are in which to calm down and gain control

A. Provide safety for the pt and other clients on the unit

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistency disrupts the group's interactions. Which intervention should the nurse initially implement? A. Setting limits on the client's behavior. B. Asking the client to leave the group session C. Asking another nurse to escort the pt out of the group session. D. Telling the client that they will not be able to attend any future group sessions.

A. Setting limits on the client's behavior.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? A. The teen gives a way a DVD and a cherished autographed picture of a performer. B. The teen runs out of the therapy group, swearing at the group leader, and to her room. C. The teen becomes angry while speaking on the phone and slams down the receiver. D. The teen gets angry with her roommate when the roommate borrows the client's clothes without asking.

A. The teen gives a way a DVD and a cherished autographed picture of a performer.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? A. Move the client next to the nurse's station. B. Use an indirect light source and turn off the television C. Keep the TV and a soft light on during the night D. Play soft music during the night, and maintain a well-lit room.

B. Use an indirect light source and turn off the television (initial; next can be moving the pt close to nurse's station)

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? A. Chess B. Writing C. Ping pong D. Basket ball

B. Writing (solitary)

The nurse is the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? A. Signs of depression B. Reactions to a devastating event C. Evidence that client is a high suicide risk D. Indicative of the need for hospital admission

B. Reactions to a devastating event (during acute phase of the rape crisis, the client can display wide range of emotional and somatic responses)

A nurse notes that a client with schz and receiving an antipsychotic med is moving her mouth, protruding her tongue, and grimacing as she watches TV. The nurse determines that the client is experiencing which medication complication? A. Parkinsonism B. Tardive dyskinesia C. HTN crisis D. NMS

B. Tardive dyskinesia

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care fro the client, determining that this type of crisis could be caused by which event? A. Witnessing a murder B. The death of a loved one C. A fire that destroyed the client's home D. A recent rape episode experienced by the client

B. The death of a loved one Rationale: - A situational crisis arises from external rather than internal source: (external: loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of a new family member) - A, C, D identify adventitious crisis ( may result from natural disaster, national disaster, a crime of violence

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? A. "I don't believe this is true." B. "The guards are not out to kill you." C. "Do you feel afraid that people are trying to hurt you?" D. "What makes you think the guards were sent to hurt you?"

C. "Do you feel afraid that people are trying to hurt you?"

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? A. "You need to try to be realistic. The rape did not just occur." B. "It will take some time to get over these feelings about your rape." C. "Tell me more about the incident that causes you to feel like the rape just occurred." D. "What do you think that you can do to alleviate some of your fears about being raped again?"

C. "Tell me more about the incident that causes you to feel like the rape just occurred."

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and it making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client. A. "You need to stop that behavior." B. "You will need to be placed in seclusion." C. "You seem restless; tell me what is happening." D. "You will need to be restrained if you do not change your behavior."

C. "You seem restless; tell me what is happening."

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? A. Requesting that a peer remain with the client at all times B. Removing the client's clothing and placing the client in a hospital gown C. Assigning to the client to a staff member who will remain with the client at all times D. Admitting the client to a seclusion room where all potentially dangerous articles are removed

C. Assigning to the client to a staff member who will remain with the client at all times

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the pt becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? A. Place the client in seclusion for 30 mins B. Tell the client that the behavior is inappropriate C. Escort the client to their room, with the assistance of other staff. D. Tell the client that their telephone privileges are revoked for 24 hours

C. Escort the client to their room, with the assistance of other staff.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I am finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? A. Suggesting a reduction of medication B. Allowing increased "in-room" activities C. Increasing the level of suicide precautions D. Allowing the client off-unit privileges as needed

C. Increasing the level of suicide precautions

A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the perception of the precipitating event that led to the crisis, which is the most appropriate question? A. With whom do you live? B. Who is available to help you? C. What leads you to seek help now? D. What do you usually do to feel better?

C. What leads you to seek help now?

The nurse is preparing a client with a hx of command hallucinations for dc by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional info? A. "My med will help my anxious feelings." B. "I'll go to support group and talk about what I am feeling." C. "I need to get enough sleep and eat well to help prevent felling anxious." D. "When I have command hallucinations, I'll call a friend and ask him what I should do."

D. "When I have command hallucinations, I'll call a friend and ask him what I should do."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? A. "Have you talked to your family about this?" B. "Everyone feels this way when they are depressed." C. "You will feel better once your medication begins to work." D. "You sound very upset. Are you thinking of hurting yourself?"

D. "You sound very upset. Are you thinking of hurting yourself?"

The nurse is creating a plan of care for a client in crisis state. When developing the plan, the nurse should consider which factor? A. A crisis state indicates that the client has a mental illness. B. A crisis state indicates that the client has an emotional illness C. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. D. A client's response to a crisis for one client may not constitues a crisis fro another client.

D. A client's response to a crisis for one client may not constitues a crisis fro another client.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes of LOC, hallucinations

D. Hypertension, changes of LOC, hallucinations