Mental Health Online Practice A & B with NGN

A nurse is reviewing the MAR for a client who is experiencing adverse effects of chlorpromazine. the nurse should administer benztropine to relieve which of the following adverse effects? a. Blurred vision b. Orthostatic hypotension c. Dry mouth d. Acute dystonia

d. Acute dystonia

A nurse is assessing a school age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? a. Feelings of remorse b. Extended periods of depression c. Deficits in intellectual functioning d. Aggression toward animals

d. Aggression toward animals

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the clients turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? a. Allow the client time to formulate an answer b. Prompt the client to give a response c. Move on to the next client d. Offer the client a suggestion for a goal

a. Allow the client time to formulate an answer

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? a. Arrange one to one observation of the client b. Encourage interaction with the clients peers c. Administer medication for depressive disorder d. Encourage the client to attend a support group

a. Arrange one to one observation of the client

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, im red in the head, and I'm going to bed! The nurse should document the client's speech patterns which of the following? a. Clang association b. Word salad c. Neologisms d. Echolalia

a. Clang association

A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take> a. Do not administer the lorazepam b. Request a prescription for IV lorazepam c. Request that another nurse attempt to administer the lorazepam d. Place the lorazepam in the clients food

a. Do not administer the lorazepam

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. Emotional lability b. Self sacrificing c. Suspicious of others d. Grandiosity

a. Emotional lability

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? a. Encourage the client to drink 125 mL of fluid each hour while awake. b. Allow the client to eat independently in their room c. Weight the client twice weekly d. Measure the client's vital signs once each day

a. Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) a. Feelings of hopelessness b. Pressured speech c. Grandiosity d. Anhedonia e. Flat facial expression

a. Feelings of hopelessness d. Anhedonia e. Flat facial expression

a nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? a. I am going to order a wheelchair for when im unable to walk b. I am going to stop paying my bills since i wont be around much longer c. I wish you would go take care of somebody who actually needs you d. I am going to be able to continue to care for myself without help

a. I am going to order a wheelchair for when im unable to walk

A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? a. I should eat a regular diet with normal amounts of salt and fluids b. I should discontinue the lithium when i being to feel better c. I need to be careful to avoid becoming addicted to the lithium d. I can skip a dose of medication if my stomach is upset

a. I should eat a regular diet with normal amounts of salt and fluids

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? a. If you do my homework for me, I won't bother you for the rest of the day b. Mom is always upset c. It's not the children's fault, its mine d. It's your fault that were having problems as a family

a. If you do my homework for me, I won't bother you for the rest of the day

a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. to eat a trusting nurse client relationship, which of the following actions should the nurse take first? a. Inform the client that this admission is confidential b. Introduce the client to other clients in the day room c. Assist the client in facilitating behavior change d. Determine coping strategies that the client has used in the past

a. Inform the client that this admission is confidential

a nurse observes a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? a. It appears as though you would like to open the door b. You will feel more comfortable after you've been here for a while c. It is okay to not want to be here d. You really shouldn't be pushing on the door

a. It appears as though you would like to open the door

a client who has a recent d/x of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up too." Which of the following actions should the nurse take? a. Move the client who has bipolar disorder to a private room b. Administer sleep medication to the client who has bipolar disorder c. Move the client who has severe depression to a private room d. Administer sleep medication to the client who has severe depression

a. Move the client who has bipolar disorder to a private room

a nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? a. Nonmaleficence b. Veracity c. Justice d. Authonomy

a. Nonmaleficence

a nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? SATA a. Occupational therapy b. Meal delivery services c. Speech language pathologist d. Physical therapy e. Home health services

a. Occupational therapy b. Meal delivery services d. Physical therapy e. Home health services

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? a. Promote the use of music to compete with the client's auditory hallucinations. b. Inform the client that they auditory hallucinations are not real c. Avoid asking the client if they are experiencing auditory hallucinations d. Instruct the client on the use of voice recognition regarding the auditory hallucinations

a. Promote the use of music to compete with the client's auditory hallucinations.

A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? a. Respite care b. Partial hospitalization c. Adult day care program d. Geropsychiatric unit

a. Respite care

A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? a. St john's wort b. Saw palmetto c. Echinacea d. Ginkgo

a. St john's wort

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? a. The client is interested in what the nurse is saying. b. The client is attempting to manipulate the nurse c. The client is physically attracted to the nurse d. The client needs to feel accepted by the nurse

a. The client is interested in what the nurse is saying.

A nurse is reviewing lab results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? a. WBC count 2500/mm3 b. Hgb 11.5 mg/dL c. Platelets 15,000/mm3 d. RBC count 3.5 million/mm3

a. WBC count 2500/mm3

A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? a. A client who has a fasting blood glucose level of 80 mg/dl b. A client who has a sodium level of 128 mEq/L c. A client who has a BUN of 18 mg/dl d. A client who has a potassium level of 3.6 mEq/L

b. A client who has a sodium level of 128 mEq/L

A nurse is caring for a group of clients. Which of the following findings should the nurse report? a. A client who is taking clozapine and has a WBC count of 7500 b. A client who is taking lamotrigine and has developed a rash c. A client who is taking valproate and has a platelet count of 150000 d. A client who is taking lithium and has a lithium level of 1.2

b. A client who is taking lamotrigine and has developed a rash

A nurse in the ED is caring for 4 clients. Which of the following clients is the nurse required to report as a potential victim of abuse? a. A school age child who has bruises on the knees b. An older adult client who is bed bound and has a stage IV pressure ulcer c. An adolescent who has vaginal candida infection d. A young adult who is pregnant and has a sprained ankle

b. An older adult client who is bed bound and has a stage IV pressure ulcer

A nurse on a med surg unit is assessing a client who sustained injuries 12 hr ago following a MVA. The client's admission blood alcohol level was 325 mg/dl. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? a. Somnolence b. Blood pressure 154/96 mm Hg c. Pinpoint pupils d. Blood glucose 210 mg/dL

b. Blood pressure 154/96 mm Hg

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? a. Have the client participate in a morning aerobics group b. Encourage frequent rest periods throughout the day. c. Provide a distraction such as TV at night d. Offer the client hot chocolate at bedtime

b. Encourage frequent rest periods throughout the day.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? a. Provide teaching about the use of positive coping mechanisms b. Establish screening programs to identify at risk clients c. Refer survivors of intimate partner abuse to a legal advocacy program d. Organize rehabilitation therapy for clients who have experienced intimate partner abuse

b. Establish screening programs to identify at risk clients

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? a. Rapid improvement in affect within 30 to 60 min after taking the medication b. Greater risk of attempting suicide as affect and energy improve c. Onset of frequent, loose stool d. Development of physiologic dependence on the medication

b. Greater risk of attempting suicide as affect and energy improve

A nurse in a community health center is working with a group of clients who have PTSD. Which of the following interventions should the nurse include to reduce anxiety among the group members? a. Response prevention b. Guided imagery c. Aversion therapy d. Light therapy

b. Guided imagery

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? a. I will spend extra time at work to keep from feeling depressed b. I will talk about my feelings with a close friend c. I will be able to learn how to prevent my partners attacks d. I will use meditation instead of taking my antidepressant

b. I will talk about my feelings with a close friend

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? a. You probably want to hold your baby b. I'll stay with you just in case you want to talk c. I know how you must be feeling d. It hurts now, but things will be better soon

b. I'll stay with you just in case you want to talk

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? a. Develop a code words that means "time to go" b. Identify signs of escalation of violence c. Have a predetermined place to go in the event of violence d. Keep a hidden packed bag of necessity

b. Identify signs of escalation of violence

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? a. Include a liquid supplement with meals b. Identify the clients trigger foods c. Allow the client at least 1 hr for each meal d. Weight the client at bedtime each day

b. Identify the clients trigger foods

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? a. Obsessive attention to detail b. Inability to sleep c. Reports of fatigue d. Isolation from others

b. Inability to sleep

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? a. Advise the client to take frequent sips of water b. Instruct the client to avoid driving during initial therapy. c. Consult a dietitian for a calorie controlled diet plan d. Recommend that the client exerciser regularly

b. Instruct the client to avoid driving during initial therapy.

A nurse is planning cre for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? a. I'm relieved now that my financial affairs are in order b. It is easier to talk about my feelings now c. Suddenly i have enough energy to do anything i want d. Thank you for always taking such good care of me

b. It is easier to talk about my feelings now

a nurse is teaching the guardians of a client about their adolescent child's d/x of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? a. This disease will increase your child's risk for high blood pressure b. It is important for our child to have regular dental checkups c. We need to weight our child daily for several weeks, then once per week d. Bleeding during our childs periods will increase because of this disease

b. It is important for our child to have regular dental checkups

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? a. Behave in a friendly manner toward the client b. Set realistic limits on the client's behavior. c. Show respect for the clients need for isolation d. Act as a role model for assertiveness

b. Set realistic limits on the client's behavior.

A nurse is caring for a client who is undergoing ECT and will receive succinylcholine. The client asks the nurse about this mediation. Which of the following responses would the nurse make? a. Succinylcholine will enhance the therapeutic effects of the treatment b. Succinylcholine is given to reduce muscle movements during therapy c. Succinylcholine will decrease the anxiety level that you might expect with this treatment d. Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure

b. Succinylcholine is given to reduce muscle movements during therapy

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? a. The clients chart indicates a 1.36 kg (3 lb) weight gain in 1 month b. The client reports an inability to breathe easily. c. The clients lab results indicate a fasting blood glucose level of 130 mg/dL d. The client reports having recently started smoking cigarettes

b. The client reports an inability to breathe easily.

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify which of the following findings indicates a potential psychiatric emergency? a. The client is exhibits echolalia b. The client reports command hallucinations c. The client reports loss of motivation d. The client is exhibiting blunted affect

b. The client reports command hallucinations

A nurse is discussing a 12 step program with a client who has an alcohol use disorder and is in an acute care facility undergoing detox. Which of the following info should the nurse include in the teaching? a. The program will help the client accept responsibility for the disorder b. The client should obtain a sponsor before discharge for an increased chance of recovery c. The client will need to identify individuals who have contributed to the disorder d. The program will need a prescription form the clients provider prior to attendance

b. The client should obtain a sponsor before discharge for an increased chance of recovery

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? a. You might notice an increase in saliva while taking this medication b. You might experience difficulties with sexual function while taking this medication c. You should expect an improvement in symptoms of depression in 3 to 4 days d. You may notice a temporary ringing in the ears when starting this medication

b. You might experience difficulties with sexual function while taking this medication

a nurse is caring for four clients in an ED. the nurse should identify which of the following clients can give informed consent? a. A 17 year old client who lives with friends b. A 50 year old client who has a blood alcohol level of 80 mg/dL c. A 35 year old client who has major depressive disorder d. A 65 year old client who just received a dose of morphine

c. A 35 year old client who has major depressive disorder

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? a. A client refuses electroconvulsive therapy after signing the consent form b. A client who was voluntarily admitted left the unit against medical advice c. A client was administered one-half of the prescribed dose of medication. d. A client was placed in restraints after attempted to de escalate aggressive behaviors failed

c. A client was administered one-half of the prescribed dose of medication.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? a. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners b. A client who has depression reports having a lack of interest in assisting their partner in the care of their children c. A client who has borderline personality disorder threatened to harm their roommate. d. An adolescent client who has anorexia nervosa has a BMI of 17

c. A client who has borderline personality disorder threatened to harm their roommate.

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? a. Delusions b. Neologisms c. Anhedonia c. Echopraxia

c. Anhedonia

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? a. Call the family member to the side to inquire if they have questions or concerns about the treatment plan b. Advise the family member that this treatment plan has been developed specifically for the client to follow c. Ask the family member if they have any thoughts or questions about the treatment plan. d. Document that the family member does not support the medication treatment plan

c. Ask the family member if they have any thoughts or questions about the treatment plan.

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? a. Offering self b. Use of silence c. Attention to body language d. Reflection of feelings

c. Attention to body language

a nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? a. Call the provider to obtain an immediate prescription for restraint b. Prepare to administer benzodiazepine IM c. Call for a team of staff members to help with the situation d. Check the client who was hit for injuries

c. Call for a team of staff members to help with the situation

A charge nurse in a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? a. Clients cant refuse to take medications if they are admitted involuntarily b. You can notify a clients family if they are admitted involuntarily c. Clients who are admitted involuntarily maintain the right to give informed consent for procedures d. You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions

c. Clients who are admitted involuntarily maintain the right to give informed consent for procedures

A nurse in a provider's office is collecting a health history form the guardian of a school age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? a. Reduced appetite b. Fatigue c. Dark urine d. Sweating

c. Dark urine

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? a. Sore throat b. Photophobia c. Hand tremors d. Constipation

c. Hand tremors

a nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. the nurse should identify which of the following statements by the client's partner indicates an understanding of the teaching? a. I will avoid social events until my partner has completed treatment b. It is important for me to focus my attention on my partners addiction c. I will not take charge of my partners work responsibilities d. I want my partner to promise to change addictive behaviors

c. I will not take charge of my partners work responsibilities

a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I will use the same plan of care and interventions for each client who has depression b. Each nurse will develop a separate plan of care for each client who has depression c. I will update the plan of care as a clients manifestations of depression change d. An assistive personnel can use the plan of care for client teaching

c. I will update the plan of care as a clients manifestations of depression change

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? a. Raise the pitch of the voice when speaking to the client b. Being the interview by explaining the plan of care c. Interview the client in a private setting d. Ask the client to complete a detailed questionnaire

c. Interview the client in a private setting

a nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? a. Why do you think you deserve this punishment? b. Don't worry about being punished by god c. Let's talk about what is upsetting you d. You shouldn't say things that will upset you so much

c. Let's talk about what is upsetting you

A nurse is assessing a family's dynamics during a counseling session. the nurse should recognize which of the following findings as an indication of a boundary issue? a. An adolescent family member who questions parental authority b. A family with three generations in the same household c. Older children who are responsible for their younger siblings d. Two adults and their children from prior relationships in the same household

c. Older children who are responsible for their younger siblings

a nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the child's plan of care? a. Offer the client various choices for meal selection b. Assign different nursing personnel for each shirt c. Permit the client to perform daily rituals to decrease anxiety d. Maintain an environment that has low lighting

c. Permit the client to perform daily rituals to decrease anxiety

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse? a. Schedule the client for group therapy sessions b. Maintain consistent rules c. Provide frequent high-calorie snacks. d. Avoid the use of value judgements

c. Provide frequent high-calorie snacks.

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? a. Controls anger outbursts to avoid being placed in seclusion b. No longer exhibits a fear of social of public situations c. Refrains from manipulating others to earn dining room privileges d. Imitates the therapist's use of a relaxation technique

c. Refrains from manipulating others to earn dining room privileges

a nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? a. Document the client's behavior every 8 hr b. Limit the client's fluid intake to 50 mL/hr c. Renew the prescription for the client every 4 hr d. Toilet the client every 4 hr

c. Renew the prescription for the client every 4 hr

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? a. Male gender b. Hyperthyroidism c. Substance use disorder d. Being married

c. Substance use disorder

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? a. Encourage the parents to avoid discussing the death with their other children to project their feelings b. Recommend each parent grieve in private to avoid hindering each others healing c. Suggest forming a weekly support group for parents who have experienced the death of a child d. Advice the parents to begin counseling if they are still grieving in a few months

c. Suggest forming a weekly support group for parents who have experienced the death of a child

A nurse is caring for a child who is taking methylphenidate. the nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? a. Weight gain b. Tinnitus c. Tachycardia d. Increased salivation

c. Tachycardia

A nurse is assessing a client for risk factors for the development of depression. the nurse should identify which of the following factors places the client at an increased risk for depression? a. The client is married b. The client recently received a promotion at work c. The client has COPD d. The client is male

c. The client has COPD

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? a. The client will take prescribed medications as scheduled b. The client will express feelings of frustrations c. The client will refrain from self mutilation d. The client will participate in group therapy

c. The client will refrain from self mutilation

A nurse in an acute mental health facility is receiving a change of shift report on four clients. Which of the following clients should the nurse assess first? a. A client who does not recognize familiar people b. A client who cannot verbalize their needs c. A client who is awake and disoriented at night d. A client who is experiencing delusions of persecution

d. A client who is experiencing delusions of persecution

A nurse is receiving a change of shift report for four clients. Which of the following clients should the nurse plan to see first? a. A client who has avoidant personality disorder and refuses to attend group therapy b. A client who has bipolar disorder and reports being kidnapped by aliens overnight c. A client who is taking bupropion and reports having insomnia the past 2 nights d. A client who is taking clozapine and reports a sore throat and chills

d. A client who is taking clozapine and reports a sore throat and chills

A nurse in a mental health unit is admitting a client who is anxious and tells the nurse, I hear voices telling me what to do. Which of the following actions should the nurse take> a. Tell the client that the voices do not really exist b. Touch the client to help reduce feelings of anxiety c. Instruct the client to go to a quiet room when the voices start talking d. Ask the client what the voices are saying

d. Ask the client what the voices are saying

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. the nurse should identify which of the following treatment options can offer interdisciplinary services for the client at home? a. Community mental health center b. Mental health day program c. Partial hospitalization program d. Assertive community treatment

d. Assertive community treatment

A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? a. Ensure a family member can be present during treatment b. Increase fluid intake for 24 hr before the treatment starts c. Change position slowly when the treatment is complete d. Avoid looking directly at the light during treatment

d. Avoid looking directly at the light during treatment

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Obtain the weight of a client who has bipolar disorder and is experiencing mania b. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days c. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome d. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

d. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

A nurse in a mental health facility is caring for a client who has schizophrenia. which of the following findings places the client at the greatest risk for self directed injury or injuring others a. Inability to communicate with others b. Feelings of absence of self worth c. Lack of motivation to perform daily tasks d. Command hallucinations

d. Command hallucinations

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? a. Slow onset b. Aphasia c. Confabulation d. Easily distracted

d. Easily distracted

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? a. Inability to recognize family members b. Chooses clothing that is inappropriate for the weather c. Exhibits a change in personality d. Frequently misplaces objects

d. Frequently misplaces objects

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? a. I put in extra hours at work so i wont think about drinking b. I know that wine is good for my heart, so that's why i drink some each evening c. I make up for my drinking by taking my partner on nice vacations d. I am able to go to work every day, so I don't have a problem.

d. I am able to go to work every day, so I don't have a problem.

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? a. Information regarding clients should remain confidential until after their death b. Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states c. As long as the client identity is disguised, their health information can be shared between professionals on the internet d. In the event a client threatens harm to others, medications can be administered without consent

d. In the event a client threatens harm to others, medications can be administered without consent

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? a. Increased confusion b. Sleep disturbances c. Cluttered environment d. Inappropriate dress

d. Inappropriate dress

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? a. It will be better for you to keep busy to avoid thinking about your child's death b. You will complete the grieving process about a year after your child's death c. The grief process will start once your child actually dies d. It is not uncommon to feel angry toward yourself or others

d. It is not uncommon to feel angry toward yourself or others

a nurse is educating the parent of a child who has a new d/x of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? a. Fear of abandonment b. Motor and verbal tics c. Hostile behavior d. Language delay

d. Language delay

a nurse is planning care for a client who has GAD. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? a. Panic b. Moderate c. Severe d. Mild

d. Mild

A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? a. Diarrhea b. Heavy menstrual bleeding c. Tachycardia d. Orthostatic hypotension

d. Orthostatic hypotension

a nurse is admitting a client who has MDD and a new Rx for tranylcypromine. Which of the following OTC meds that the client reports taking should the nurse alert as a potential A/E? a. Lansoprazole b. Naproxen c. Magnesium hydroxide d. Phenylephrine

d. Phenylephrine

A nurse is caring for a child who has a conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic interventions is the priority? a. Encourage expression of feelings b. Support the child's attendance at an assertiveness training group c. Assist the child to perform relaxation breathing d. Reduce environmental stimuli

d. Reduce environmental stimuli

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? a. Decrease distractions during meal times b. Provide positive feedback when the child completes a task c. Clearly identify consequences for unacceptable behavior d. Remove unnecessary equipment from the child's surroundings.

d. Remove unnecessary equipment from the child's surroundings.

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse make? a. Confront the staff member b. Encourage the client to report the incident c. Document the incident in the client's health record d. Report the occurrence to the charge nurse

d. Report the occurrence to the charge nurse

A nurse in a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? a. Allowing a client to choose which unit activities to attend b. Attempting alternative therapies instead of restraints for a client who is combative c. Providing a client with accurate information about their prognosis d. Spending adequate time with a client who is verbally abusive

d. Spending adequate time with a client who is verbally abusive

A nurse in a mental health clinic is planning care for 4 clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? a. Discuss outpatient resources with a client who has post traumatic stress disorder b. Create a plan of care for a client who is experiencing alcohol withdrawal c. Explain sleep hygiene to a client who has insomnia d. Stay with a client who has anorexia nervosa for 1 hr after mealtimes

d. Stay with a client who has anorexia nervosa for 1 hr after mealtimes

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? a. Move the client to a room near the nurses station b. Limit visitors until the client is oriented to the environment c. Tell the client that their partner is deceased d. Talk with the client about activities they enjoyed with their partner

d. Talk with the client about activities they enjoyed with their partner

A nurse is assessing a client who has bulimia nervosa. the nurse should expect which of the following findings? a. Amenorrhea b. Lanugo c. Cold extremities d. Tooth erosion

d. Tooth erosion