Mental Health
A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the ED by police. The client can state the their name and address, but has no recollection of the past 2 days. What is the priority nursing action? A. assess VS B. contact family C. encourage the client to recall recent events D. perform a mental status assessment
A
A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "i only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? A. denial and projection B. rationalization and depression C. regression and displacement D. sublimation and reaction formation
A
A client who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "i'm not hungry and I don't feel like doing anything." What is the best response by the nurse? A. i will help you get ready; then we can walk to the dining room together. B. i'll have breakfast brought to your room C. it's okay. you can join us when you are ready D. you'll feel better when you get up
A
A client with borderline personality disorder says to the nurse, "you're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? A. assign different staff members to care for the client each day B. continue assigning the client's stated preferred nurse to care for the client C. frequently reassure the client that all staff members are competent D. reinforce unit rules and consequences of inappropriate behaviors
A
A client with moderate Alzheimer disease is started on memantine. In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? A. improved ability to perform activities of daily living B. indications that disease progression has stopped C. rapid improvement in cognitive functioning D. reversal of the disease
A
A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching tv, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client? A. a board game with a staff member B. participation in a group songfest C. planning a unit picnic D. playing bingo with other clients
A
A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? A. complete blood count and absolute neutrophil count B. ECG and BP C. fasting blood glucose and fasting lipid panel D. height, weight, and waist circumference
A
The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the BEST explanation for these clinical characteristics? A. The client is attempting to maintain self-esteem B. The client is experiencing delusions of grandeur C. The client is feeling threatened D. The client is trying to prevent a panic attack
A
The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being mot at risk for suicide? A. divorced male with Parkinson's who was recently laid off from his job B. married female with breast cancer whose daughter is going through a divorce C. married male, newly retired, who is active in community outreach programs D. newly divorced female with type 2 DM who has custody of 3 children
A
The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment? A. "i am looking for another heart specialist to evaluate symptoms" B. "i asked my spouse for support while i deal with my mother's death" C. "i have started carrying a sketchbook to draw in when i am stressed" D. "i journal daily about my stress level and any heart-related symptoms"
A
The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior? A. during 1-2 hours after each meal B. during every meal C. during the evening meal D. during the overnight hours
A
The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "there's a bad man standing over there in the corner of my room." What is the best response by the nurse? A. "i know you are frightened, but I do not see a man in your room." B. "i'll make the bad man go away" C. "let's go to the dayroom and play checkers" D. "your illness is making you hallucinate"
A
The nurse is conducting a seminar for parents of adolescents about health issues common to this age group. Which parent's statement indicates that the adolescent may have bulimia nervosa? A. i have found several empty boxes of laxatives in my child's wastebasket B. i have noticed my child has started wearing bulky, oversized clothing C. my child has lost 20lb in the past 2 months D. my child has stopped going to the gym
A
A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? A. encouraging visits by friends to decrease social isolation B. giving the client a schedule of daily activities C. placing the client in restraints during invasive procedures D. providing the client with a variety of toys
B
A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child? A. child's favorite stuffed animal B. connect-the-dots puzzle book C. putting together a 300-piece jigsaw puzzle D. writing in a journal about the hospital stay
B
A client is receiving NG tube feeds as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb and says to the nurse, "see what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse? A. have the client keep a journal and write about feelings B. initiate one-on-one supervision of the client during feedings C. remind the client that gaining weight means being able to go home D. say that the client is not fat and ugly
B
A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "i can't find my headband. i can't find my headband. the oil is going to leak out of the crack in my head." What is the best response by the nurse? A. how long has the oil been leaking from your head? B. let's go back to your room and look for your headband together. C. there is no oil coming out of your head D. you are going to miss breakfast if you fo not go into the dining room.
B
A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? A. give the client a book to read B. rpovide earphones and a DVD player and have the client sing along with the music C. tell the client that the voices will go away when the medication starts to work D. tell the client to ignore the voices
B
A client with schizophrenia says to the nurse, "the world turns as the world turns on a ball at the beach. but the world's stagecoach and i took the bus home." The nurse recognizes this statement as an example of which of the following? A. concrete thinking B. loose associations C. tangentiality D. word salad
B
A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy? A. the client and spouse are soon moving to a new neighborhood B. the client's boss has asked them to represent the company at an upcoming convention C. the client's HCP of 30 years is retiring and the client will be seeing a new HCP D. the client's son is getting married in a few months
B
A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity? A. "do you prefer being referred to as 'he' or 'she'?" B. "how would you describe your gender?" C. "what gender were you originally?" D. "what is your preferred name?"
B
A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent? A. administer prescribed PRN lorazepam and apply soft wrist restraints B. explain all activities of care clearly and calmly while facing the client C. place the client in the room that is closest to the nurses station D. request security personnel to be present to protect clients and staff
B
A registered nurse is leading a support group for partners of military veterans suffering from PTSD. A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms? A. auditory hallucinations, feelings of paranoia, isolation from others B. increased anxiety, reliving the event, feeling detached from others C. rapidly changing emotions, delusions, lethargy D. recurring nightmares, uncontrollable anger, daytime sleepiness
B
After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice. "this is terrible. i'm so fat." What is the best response by the nurse? A. "but you look so thin" B. "i don't see you that way; you are making progress toward a healthy weight" C. "if you continue to gain weight at this rate, you will be able to go home soon" D. "you are not fat; it's all in your imagination"
B
An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? A. don't you know it is not morning yet? B. it is time to get back to bed now. C. you might fall if you wander in the dark D. you should not leave your room without assistance.
B
The clinic nurse reviews telephone messages left by 4 clients. Which client is the priority to call back first? A. client recovering from opioid addiction having cravings after losing job B. client with schizophrenia hearing voices advising to harm a neighbor C. parent of a client with conduct disorder who refuses to leave a locked room D. spouse of a client with depression reporting the client is threatening suicide
B
The home health aide reports to the case manager that the client has been trying to give away possessions. When the nurse asks the client about his behavior, the client says, "with my spouse dead, theres no reason for me to go on." What is the best priority response by the nurse? A. "do you have any friends in the building?" B. ""have you had any thoughts of hurting yourself?" C. "Tell me more about how you're feeling." D. "You're not thinking of killing yourself are you?"
B
The nurse assigned to care for a client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? A. fears abandonment, agreeable, needs constant reassurance B. likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration C. seems uncomfortable around people, lack of close friends, indifferent to praise or criticism D. tries to intimidate others, manipulative, lacks empathy
B
The nurse cares for a client who just had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am i going to die?" Which statement by the nurse is appropriate? A. i know how anxious you must be. watching some television might help you relax B. tell me more about your thoughts and feelings regarding the situation C. the biopsy results show that you have cancer, but many cancers are treatable D. waiting for test results can be stressful. I am sorry i cannot tell you more
B
The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? A. baked sweet potato, kale, yeast roll, water B. cheeseburger, apple, vanilla milkshake C. spaghetti with meatballs, fruit salad, milk D. veggie soup, salad, dinner roll, iced tea
B
The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior? A. the client has a problem with authority figures B. the client has an intense need to control the environment C. the client is hearing voices D. the client is trying to control anger
B
The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium? A. client is alert but disoriented to time B. client is inattentive and hallucinating C. client reports decreased enjoyment in previously pleasurable activities D. family reports a gradual progressive inability to remember recent events
B
The nurse is caring for a new mother whose infant has been diagnosed with Down Syndrome. The client says to the nurse, "i'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? A. both of you will benefit from supportive counseling. B. how are you feeling about your baby? C. i will have the doctor speak to your husband D. why do you think your husband feels this way?
B
The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. Which factor best indicated the client is not currently at risk of suicide? A. client claims to have more energy and vigor since starting therapy B. client has clear future plans involving personal goals and family milestones C. client has signed a contract promising not to attempt suicide D. client reports losing prescribed amitriptyline and requests a refill
B
The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has ADHD, predominantly inattentive type. What is the priority nursing action? A. encourage the child to keep up with school work B. give the child a written schedule of daily activities C. limit the number of visitors D. provide verbal explanations of what to expect during hospitalization
B
The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, "It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore." Which response by the nurse is best? A. perhaps finding a caregiver to care for your spouse at night might be helpful B. tell me about the care you provide in a typical day and its challenges C. try not to worry. it is normal to feel overwhelmed when you are stressed D. you seem worries that you won't be able to provide the care that your spouse needs
B
The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? A. client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays B. client diagnosed with PTSD who reports an anxiety level of 8/10 and is pacing in the room C. client newly admitted with bipolar mania who reports sleeping only 4 hours last night D. client newly admitted with OCD who has spent the last hour counting socks
B
The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? A. compensation B. displacement C. projection D. reaction formation
B
The school nurse is called to the classroom to assist with a 7-year-old with ADHD who is throwing books and hitting the other children. What is the best initial action for the nurse to take? A. administer a PRN dose of methylphenidate B. ask the child to blow up a balloon C. give the child a "time out" in a quiet place D. reinforce the consequences of disruptive behaviors
B
A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? A. Allow the child to stay home when the child seems particularly anxious B. Encourage the parent/caregiver to sit in the classroom with the child C. Insist on school attendance immediately, starting with a few hours a day D. Return the child to school when the cause of the school phobia has been identified
C
A client is brought to the emergency room after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "if I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse? A. do you gave any relatives or close friends who can help you through this? B. has your spouse seemed depressed lately? C. this has been very overwhelming for you. what are you feeling right now? D. well, you did find your spouse. you need to focus on helping your spouse get better.
C
A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? A. cancer is no longer a death sentence; you may live for many years. B. i will ask the chaplain to talk to you sometime today C. people with cancer experience fear of dying; tell me about your concerns D. tell me about your life and hopes for the future
C
A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "it's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? A. "i'm sorry. I should have reminded you to sign in." B. "it is not my fault that you forgot to sign in" C. "it is your responsibility to sign in when you return from a pass." D. "you were late coming back from your pass. is that why you did not sign in?"
C
A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? A. impaired social interaction B. impaired verbal communication C. risk for deficient fluid volume D. risk for impaired skin integrity
C
A client with a history of obsessive-compulsive personality disorder is seeking treatment for a GI disorder and is scheduled for a colonoscopy at 10am. Due to a computer glitch, the procedure is postponed to 3pm. Which response would be characteristic of an individual with OCPD. A. how dare they change my appointment? i insist that the procedure be done at 10am. B. thats fine. I can come in whenever is convenient for everyone C. this is unacceptable. i had my whole day planned out D. why are they doing this to me?
C
After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the MOST IMPORTANT strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client's eye level 4. Place a safe return bracelet on the clients non-dominant hand
C
An 87-year-old client has been admitted to the hospital with s/s of a UTI along with agitation, confusion, and disorientation to time and place. What is the most important nursing action? A. encouraging frequent fluid intake B. keeping the bed elevated with the side rails raised C. providing one-on-one supervision D. turning lights off in client's room to reduce stimulation
C
An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is most helpful? A. "i am busy right now but can stay for a few minutes" B. "i can call the clergy to come sit with you." C. "i can stay and sit with you if you would like" D. "i dont think i should interrupt your family time"
C
The ED nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time? A. call social services to assist the client in community resources for domestic violence victims B. clean the facial laceration and prepare to assist the health care provider with suture placement C. have the spouse leave the room so that the client can be spoken with and examined in private D. place the arm in a shoulder sling for immobilization and prepare for an immediate x-ray
C
The RN is counseling the parent of a child recently diagnosed with ADHD, combined type. Which statement by the parent requires an intervention? A. "i should offer a choice between 2 things for my cild's clothes or meals" B. "I will need to advocate for an individualized educational plan for my child" C. "My child will outgrow this disorder around age 20" D. "When talking with my child, I should not be multi-tasking."
C
The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is it." How should the nurse respond? A. you can cry and get it all out. i will stay with you B. you have dealt with diabetes; you can conquer dialysis C. you sound very discouraged and rightened D. you still have a lot to live for; think about your family.
C
The nurse is caring for a 10-year-old client diagnosed with ADHD. The client is at risk for which complication? A. delayed physical development B. intrusive thoughts C. low self-esteem D. paranoia
C
The nurse is caring for a client who entered the psychiatric ED in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse? A. i know it must be terrible to see your son like this, but he will be fine. B. most people have been permanent side effects after an episode like this C. your son will have to remain here for observation until we know more D. your son would be fine right now if he had not taken these drugs
C
The nurse is caring for a dying child on a palliative unit. Which statement by the nurse is most important to make to the parents immediately following the death of their child? A. finding support with other local grieving parents can be helpful B. self care is important at this time. take a break while the staff completes care C. some parents like to cuddle and speak to the child. take the time you need D. this must be a very difficult time. How have you dealt with loss in the past?
C
The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience? A. avoids anxiety-producing triggers B. it able to identify anxiety-reducing triggers C. practices stress reduction techniques daily D. relies on anxiolytic medication to manage symptoms
C
The nurse is providing care to a client experiencing PTSD following a terrorist attack at the client's place of worship. What is the priority nursing action? A. acknowledge the client's feelings of anger B. assess the client's support system C. encourage the client to talk about the trauma D. offer the client a PRN sleep medication
C
The nurse is speaking with the spouse of a client following a family discussion with the HCP about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond? A. i find it helpful to investigate the options. I will get you a pamphlet about hospice services B. it is hard to say what the best decision is, but i know hospice provides wonderful care. C. these decisions are challenging. tell me about your spouse's beliefs about end-of-life D. you seem overwhelmed. i'll contact a chaplain to come and talk with you about the options
C
The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? A. "I need you to get rid of these bugs that are crawling under my skin" B. "hear that? she told me to kill my father" C. "that song is a message sent to me in secret code" D. "those martians are trying to poison me with the tap water"
C
The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize? A. acknowledges poor interpersonal skills B. identifies new coping mechanisms C. increases caloric intake to gain weight D. verbalizes sources of conflict and anger
C
The nurse provides teaching for a client newly prescribes disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? A. disulfiram is not a cure for alcoholism B. importance of continuing to see a therapist C. list os everyday items containing hidden alcohol D. medical alert bracelet should identify disulfiram therapy
C
The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? A. it would be helpful if you could look at me while we talk B. we can finish out conversation later; thank you for speaking with me C. what do you see at the door? D. when you don't look at me, I feel like you don't trust me.
C
The spouse brings a client to the ED due to erratic behavior and expressions of despair. The ED is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? A. ask the client to make a verbal contract to not harm self B. document that the client is not currently suicidal C. place the client in an inside hallway with one-on-one supervision D. return the client to the waiting room with the spouse
C
A client on a medical unit received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. The morning the client was found in the bathroom trying to commit suicide by hanging using hospital down ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client? A. assess the client's risk for another suicide attempt B. encourage the client to express current feelings about the medical diagnosis C. place the client in a private room near the nurses' station D. provide continuous 1:1 observation with the client
D
A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse I know you'll be a good sport and give me a pass." What is the BEST response by the nurse? A. "I guess the day shift staff needs to be reminded of the rules." B. "The gift shop is not even open right now." C. "Why do you want to go to the gift shop?" D. "You do not have privileges for leaving the unit. I cannot give you a pass"
D
A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed," Which is the best response by the nurse? A. at the moment, i would worry more about how your sibling is doing. B. the odds are about 50-50 that you will come down with the disease as well C. would you like to talk to a health care provider about this? D. you are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia
D
A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse? A. do you need something to help you calm down? B. don't pay attention to the voices. let's go into the dayroom C. the voices are not real. tell them to go away. D. what are the voices saying to you?
D
A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? A. the nurse has encouraged exploration of the client's situation B. the nurse has shown interest in the client's concerns C. the response conveys empathy toward the client and promotes self-confidence D. the response devalues the client's feelings and gives false reassurance
D
A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the ED by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action? A. encourage the client to perform deep breathing exercises B. explore possible reasons for the episode C. place the client in a private room and tell the client to relax D. remain in the room with the client
D
A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the HCP recommends ECT as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse? A. ECT is safe and your spouse will not feel anything. B. it could take up to 3 weeks for medication to become effective. C. your spouse could die by not receiving this treatment D. your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?
D
A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning", and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take? A. ask where the client is going. B. immediately follow the client out the door C. in a loud voice, direct the client to come back to the room D. remain silent and allow the client to leave
D
A nurse is caring for a client who was admitted following a suicide attempt. Which client statement is most concerning? A. "i don't think that I will ever be okay again" B. "i feel so angry because I failed at my attempt" C. "I have been sleeping all the time lately" D. "very soon everything will be much better"
D
A nurse on the telemetry unit receives a client admitted from the ED with acute alcohol intoxication, confusion, and a diabetic tow ulcer. Which intervention would be the priority? A. assess for signs of alcohol withdrawal B. assess the need for alcohol rehabilitation referral C. let the client sleep off the alcohol intoxication D. monitor blood glucose levels during the night
D
A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the priority nursing diagnosis at this time? A. hoplessness B. ineffective coping C. risk for infection D. risk for suicide
D
The nurse cares for a client with a DNR, and notes extensive skin mottling and vital signs consistent with impending death. The client's spouse states, "I hope my spouse can hang on a little longer. Our anniversary is in 2 days." What response by the nurse is appropriate? A. tell me about your favorite anniversary memory you shared. B. that would be very special, but please understand that it may not happen C. we never know; death happens in its own time despite what we may want D. your spouse's body is shutting down and the time is near; I will stay here with you.
D
The nurse is caring for a client with a history of heroin abuse. Which clinical finding my indicate withdrawal? A. constipation B. constricted pupils C. drowsiness D. tachycardia
D
The spouse of a client with borderline personality disorder calls the clinic and reports that the client has self-inflicted superficial lacerations to the arm. The spouse tells the nurse, "When I prepare to travel for work, my spouse does this to stop me from leaving. It's not an attempt of serious harm." What is the best response by the nurse? A. are you still planning to leave for your trip? B. it sounds like you are having a difficult time coping with your spouse's behavior C. your spouse is most likely doing this to gain attention, so it is best to ignore the behavior D. your spouse should be seen in the clinic today
D
The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. A. client has had school disciplinary issues due to absenteeism and angry outbursts B. client has lost approximately 8lb over the last 3 weeks without trying C. client is often found sleeping during class or activities D. client quit sports despite receiving athletic awards and trophies E. client voices concern about appearance related to facial acne
a, b, c, d
The nurse is caring for a client who is experiencing active suicidal ideation. Which of the following interventions are appropriate? Select all that apply. A. conduct a suicide risk assessment B. perform mouth checks during medication administration C. place the client on one-to-one observation D. prepare the client for discharge to an intensive outpatient program E. remove the client's necklace and shoelaces
a, b, c, e
The nurse plans care for a client newly admitted with OCD who is repeatedly counting magazines in the common room. Which of the following should the nurse include in the initial plan of care? Select all that apply. A. assist the client the identify circumstances that increase anxiety B. provide positive feedback when the client attends a group activity C. refrain from judgmental comments about counting magazines D. remove the magazines from the commons room E. teach the client how to use the technique of thought stopping
a, b, c, e
A nurse performs an initial assessment on a client with suspected PTSD. Which assessments would support the diagnosis? Select all that apply. A. difficulty concentrating B. feeling detached from others C. feeling lethargic and apathetic D. flashbacks of the traumatic event E. persistent angry, fearful mood
a, b, d, e
The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. A. client breaks eye contact when discussing caregiver B. client has lost 8lb in the previous 4 weeks C. client is wearing clothing that is out of style D. client's eyeglasses have been visibly broken for 1 month E. client's prescription medication is expired
a, b, d, e
The mental health nurse is planning care for a client newly admitted with DID. Which interventions will the nurse include? Select all that apply. A. develop a trusting relationship with each of the alternate identities B. encourage the client to journal about feelings and dissociative triggers C. explain to the client in detail the events of missing memories and lost time D. listen for expressing of self-harm from the alternate identities E. teach grounding techniques such as deep breathing to hinder dissociation
a, b, d, e
Which of the following actions would the nurse include in planning care for a client hospitalized with bipolar disorder, acute manic episode? Select all that apply A. assign the client to a private room B. choose clothing for the client C. have the client be in charge of planning an outing for the unit D. have the client join other client in the dining room for meals E. have the client participate in physical exercise with a staff member F. include the client in group therapy sessions
a, b, e
The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply. A. how would you describe your child's usual behavior at home? B. these bruises seem excessive and suspicious. how did they happen? C. what forms of discipline do you use with your child? D. when you are stressed, what coping mechanisms do you use? E. who watches your child when you are at work?
a, c, d, e
The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. Which of the following communications by the nurse are appropriate? Select all that apply. A. "how has this situation affected your relationships with family and friends?" B. "It is important to focus on coping strategies and not dwell on the event" C. "it is normal to experience difficult symptoms after a traumatic event" D. "please tell me about your current use of alcohol and any drugs" E. "share with me any thoughts or plans of self-harm that you have had"
a, c, d, e
The triage nurse is assessing a client's risk for suicide after the client reports having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply. A. "i am currently unemployed and looking for a job" B. "I have been married for 5 years with 3 children" C. "I have multiple firearms at home stored in a safe" D. "it has been about a year since I last OD-ed" E. "my family and I attend weekly religious activities" F. "sometimes I experience feelings of hopelessness"
a, c, d, f
A nursing home client with major depressive disorder reports difficulty going to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary. What interventions should be included in the client's nursing care plan? Select all that apply. 1. Allow the client to receive at least 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Spend time with the client in a quiet environment just before bedtime 5. Suggest that the client take a warm bath before going to bed
a, d, e
The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply. A. drinking led to my divorce and the loss of my children B. i am in control now; i drink only on special occasions C. i will have no desire to drink once i get over my divorce D. my focus is now on fitness training and going back to college E. when cravings occur, i call my AA sponsor
a, d, e
A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. A. desensitization to a specific stimulus or situation B. discussing the interpersonal difficulties that have led to the client's psychological problems C. helping the client develop insight into the psychological causes of the disorder D. relaxation techniques E. self-observation and monitoring F. teaching new coping skills and techniques to reframe thinking
a, d, e, f
A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply. A. explore the meaning behind the client's delusions B. focus on reality and verbally reinforce it C. focus on the client's feelings secondary to the delusions D. gently confront the client about the false beliefs E. present logical explanations to discredit the delusions
b, c
The ED nurse cares for a client who college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. A. client has been sleeping on the floor in the den rather than the bed B. client has refused food and water for 4 days and has poor skin turgor C. client repeatedly mumbles, "i must kill them before they get me" D. marijuana was found in the client's personal belongings E. the health care provider makes a diagnosis of schizophrenia
b, c
The nurse in the ED is caring for a client at 10 weeks gestation who reports being abused by her spouse but is not ready to leave the relationship. Which of the following interventions are appropriate? Select all that apply. A. advise the client to avoid triggering the spouse's behavior B. assess the client for thoughts of self-harm C. collaborate with the health care team to develop a safety plan D. document the client's injuries on a body map E. encourage the client to live with a relative for the duration of the pregnancy
b, c, d
The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client. Select all that apply. A. allow the client to continue to exercise per usual routine B. assist the client in reflecting on triggers of disordered eating C. maintain strict record of protein and calorie intake D. remain with the client for the duration of each meal E. weigh the client each morning prior to any oral intake
b, c, d, e
The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. Which of the following client statements demonstrate an improvement in coping? Select all that apply? A. "I plan dates involving outdoor activities, such as hiking, instead of going to dinner and a movie" B. "i sat in the pizza shop and drank cola while watching people eat, then i bought a slice to go" C. "i started having lunch with my coworkers even though i still become very anxious eating in public" D. "i went out of town on the day of the company picnic instead of making excuses for not eating" E. "i went to a coffee house with my boss and focused on an upcoming project while drinking a latte"
b, c, e
The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. A. bradypnea B. diaphoresis C. hallucinations D. lethargy E. tachycardia
b, c, e
A client with moderate Alzheimer's disease becomes agitated during mealtime and throws a plate of flood on the floor. Which of the following responses by the nurse are appropriate? Select all that apply. A. administer a dose of prescribed PRN haloperidol before the client's behavior escalates further B. distract and redirect by asking for help folding napkins for the following day's meals C. inform the client that the HCP will be notified about the inappropriate behavior D. promptly obtain another plate of food and insist that the unlicensed assistive personnel feed the client E. use direct eye contact and say to the client, "I can see that you are upset; this is a safe place"
b, e
The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply. A. intimate partner violence is most common in low-income families B. intimate partner violence is rare in same-sex partnership C. the abusive partner often demonstrates jealousy and possessiveness D. victims may not leave due to financial concerns or fear of harm by the abuser E. violence against a female often intensifies during pregnancy
c, d, e
The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply. A. "I am focusing on my new hobby and my friends in the book club" B. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm" C. "I try to get up early and keep the children from being too loud in the mornings" D. "If I didn't get so stressed about my job, my spouse wouldn't drink so much" E. "When my spouse was sick, I called and rescheduled clients so my spouse could rest"
c, d, e
A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply A. a friend of mine passed away recently. i know how hard losses can be. B. i see that you're upset. i will step out while you process these feelings C. it may take a while, but coming to terms with loss gets easier with time D. this is a difficult time. tell me about how you have been coping E. what are your thoughts about attending a grief support group?
d, e
The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises, the child begins to cry and states, "somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. A. how long have your parents been doing things to you? B. tell me about what happened. I promise not to tell anyone. C. this is terrible. whoever did this to you will be sorry. D. what happened is not your fault. you are not to blame. E. you did the right thing by telling me. you are not in trouble
d, e
