Nclex mastery
A nurse completes an intake assessment on a teenager with a diagnosis of bipolar disorder admitted for a major depressive episode. Which questions does the nurse ask to <strong>best</strong> gather information?
"1). <b>""Tell me about your sleep patterns over the last week.""</b><div><div>- This is an open-ended question which may allow the client to provide some insight into triggers for depression.</div></div><div>2). <b>""For what reason did your parents bring you to the clinic?""</b></div><div><div>- This is an open-ended question that allows the client to elaborate on concerns or issues related to hospital admission.</div></div>"
A nurse cares for a client admitted with anorexia nervosa. Which signs and symptoms is the nurse likely to observe?
"1). <b>The client has lanugo on the face and back.</b><div><div>- Clients with anorexia nervosa experience a drop in their metabolic rate due to starvation. The slowed metabolic rate causes the clients to feel cold. The body compensates by growing lanugo, a fine, downy hair, in an attempt to insulate the body.</div></div><div>2). <span style=""font-weight: 700;"">The client reports numbness in the feet.</span></div><div>3).<b> The client has a potassium level of 3.2 mEq/L.</b></div>" 3.2 a client has level of potassium The
A client is being treated for mania with lithium. What teaching does the nurse include?
"1). <b>This medication causes weight gain.</b><br>2). <b>You will require frequent blood tests.</b><br>- Lithium has a narrow therapeutic index and requires monitoring to avoid toxic or subtherapeutic levels. It also affects serum sodium levels, so these may also need to be monitored.<br>3). <span style=""font-weight: 700;"">""Maintain an intake of 2-3 liters of fluid a day.""<br></span>- The client should maintain a healthy glomerular filtration rate (GFR) to improve renal clearance of lithium. Dehydration slows the GFR and can lead to increased serum lithium levels."
"The nurse works with a group of clients with mental illness. In what order does the nurse identify each client's risk for suicide? (Place each option in order from most at risk to least at risk.)<br><div>- Client diagnosed with obsessive compulsive disorder.</div><div><img src="""">- Client diagnosed with antisocial personality disorder.</div><div><img src="""">- Client diagnosed with major depression.</div><div><img src="""">- Client with active substance abuse.</div><div><img src="""">- Client diagnosed with schizophrenia.</div>"
"1). Client diagnosed with obsessive compulsive disorder.<br>2). Client with active substance abuse.<br>3). Client diagnosed with schizophrenia.<br>4). Client diagnosed with obsessive compulsive disorder.<br>5). Client diagnosed with antisocial personality disorder.<br> - Suicidal ideation results from feelings of hopelessness and helplessness. Mental illness is present in 90% of clients who have completed suicides. While the individual variation of suicide risk must be assessed, statistics help guide the nurse's assessment and the nurse should be aware that the <u>top three psychiatric conditions associated with suicide</u> are <b>depression, substance abuse, and schizophrenia</b>. It is also important to <u>screen for overlap of these conditions</u> that can further increase this risk."
"A nurse teaches a client about taking buspirone. Which statement made by the client indicates further teaching is required?<br>1). ""I should take this medication everyday.""<br>2). ""Is it normal for me to feel anuseous after taking this medication?""<br>3). ""I can become dependent on this medication.""<br>4). ""This medication can take several weeks to work."""
"<b>3). ""I can become dependent on this medication.""<br></b> - Buspirone does not act on gamma aminobutyric acid receptors like benzodiazepines. Therefore, while effective in treating anxiety, it does not have the same sedative effects or risk for dependence."
A nurse cares for a client admitted to the mental health unit for heroin abuse. Which statement or question is <strong>most</strong> important to include in the initial history and assessment?
"<div><div>""Tell me about when you first started using heroin.""</div></div><div><div>Asking a client about what situation was occurring when first using heroin allows the client to discuss any social problems that may have contributed to the initial drug use. </div><div> </div><div>Discovering these issues may help the client to recognize deeper reasons for drug abuse which may help when trying to overcome the addiction.</div></div>"
"A client with antisocial personality disorder says to the charge nurse, ""I want Jane to be my nurse today."" How does the charge nurse respond?"
"<div><div>""We follow the set guidelines in creating the nursing assignment.""</div></div><div><div>The charge nurse should reinforce established boundaries that the client is not able to manipulate. The nurse does this without being personally critical of the request or giving the opportunity for the client to justify the request.</div></div>"
The nurse plans an educational program about suicide. The nurse includes which facts about suicide in the teaching plan?
"<div><div>1). <b>""A prior suicide attempt increases a person's risk for suicide.""</b></div></div><div><div>- A prior suicide attempt is considered a risk factor for suicide. <u>Exposure to a family, peer, or celebrity suicide also puts a person at higher risk for suicide.</u></div></div><div><div><div>2).<b> ""Having a gun in the home increases a person's risk for suicide.""</b></div></div><div><div>- Having guns or other firearms in the home is considered a risk factor for suicide.</div></div></div><div>3). <b>""Giving away special possessions may indicate suicidal thoughts.""</b></div><div><div>- Giving away special possessions is considered a risk factor for suicide.</div></div>"
"The nurse cares for an adult client with severe separation anxiety disorder. The anxiety is focused on the client's mother. What does the nurse include in the plan of care?"
"<div><div>1). <b>Offer reassurance when the client is anxious, reminding of previous visits, and referring to pictures of the two together.</b></div><div><div>- The client will experience fear that the mother may experience a devastating event that will result in permanent separation. This anxiety can be so intense that it will interfere with any other activities, so the nurse needs to attempt to make the client feel secure and offer evidence that the mother is safe if necessary and within established set limits.</div></div><div>2). <span style=""font-weight: 700;"">Help the client's mother learn how to set healthy boundaries with the client.</span></div><div>- The subject of the anxiety must be involved in the treatment plan, and the nurse will work with other team members to support the mother in limit setting and helping the client feel more secure through consistency and predictability of interactions when the mother is not present.<br></div><div>3).<b> Establish good sleep hygiene and monitor quality and quantity of sleep closely.</b></div></div><div><div>- Clients with separation anxiety often fixate on the worry when attempting to fall asleep, which creates increased anxiety and prevents sleep. When not getting adequate sleep, the client will be less able to participate in treatment and more susceptible to higher levels of anxiety.</div></div>"
"A client watching television stands up and states, ""That person on the television is talking to me."" How does the nurse respond?"
"<div><div><b>Tell the client, ""Tell me more about thinking the person on the TV is speaking to you.""</b></div></div><div><div>- When speaking with the client about the delusion, the nurse focuses on feelings the client is experiencing, separates the accurate from inaccurate beliefs, and offers alternate interpretations for the delusional thinking.</div></div>"
"<div><div><div><div>A nurse cares for an adult client who reports to the emergency department immediately after a sexual assault. Which nursing actions are appropriate?</div></div></div><div>Select All That Apply</div></div><div><div><span style=""font-weight: 600;""></span></div><div><div><div>- Ask if sexual activity was consensual. <img src=""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>- Make client sign the exam consent form.<img src=""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>- Offer a support person or crisis advocate.<img src=""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>- Offer to provide client care for injuries. <img src=""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>- Immediately contact the local law enforcement.</div></div></div><br></div>"
"<div><div><div><b>- Offer a support person or crisis advocate.</b><img src=""""></div></div></div><div></div><div><div><div><b>- Offer to provide client care for injuries. </b><img src=""""></div></div></div>"
"<div><div><div><div>The nurse cares for a group of clients in the emergency department. The nurse recognizes that which clients meet the criteria for involuntary admission to the hospital?</div></div></div><div>Select All That Apply</div></div><div><div><span style=""font-weight: 600;""></span></div><div><div><div>1). The client who cannot care for basic needs at home.</div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>2). The client having a heart attack who wants to go home. </div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>3). The client with a broken leg who is refusing surgery.<img src=""""""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>4). The client with an infection who refuses to take antibiotics. <img src=""""""""></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div>5). The client who wants to leave in order to commit suicide.</div></div></div></div>"
"<div><div><div><b>1). The client who cannot care for basic needs at home.</b></div></div></div><div><span style=""font-weight: 600;""></span></div><div><div><div><b>5). The client who wants to leave in order to commit suicide.</b></div></div></div><br>"
"A client is prescribed bupropion for smoking cessation. Which client statement concerns the nurse?<br>1). "I have seasonal affective disorder."<br>2). "I take my pill with a full meal."<br>3). ""I feel dizzy after taking a dose."<br>4). "I am using a nicotine patch.""
"<span style=""font-weight: 700;"">"I am using a nicotine patch."<br></span>- Bupropion is used as a smoking cessation aid. Concomitant use of this medication with nicotine replacement can cause high blood pressure and should be avoided."
A health care provider prescribes a single dose of IV lorazepam for an older adult client who is agitated. The nurse knows that lorazepam is safe for administration in this population for which reason?
"<span style=""font-weight: 700;"">It has a short half-life.</span>"
"The nurse cares for a client whose son recently died. The client is unable to recall the circumstances of her son's death. The nurse incorporates interventions for what form of defense mechanism?"
"<span style=""font-weight: 700;"">Repression</span>"
The nurse admits a client with severe anxiety. The nurse implements which intervention when planning client care?<br>1). Role-play situations that the client finds anxiety-provoking.<br>2). Use distraction techniques when the client appears to feel anxiety.<br>3). Avoid making direct eye contact when communicating with the client.<br>4). Avoid asking detailed questions when the client discusses anxiety.<br>
"<span style=""font-weight: 700;"">Role-play situations that the client finds anxiety-provoking.<br></span>- Role playing or modeling behaviors helps the client to try alternative behaviors and solutions to anxiety-provoking situations."
"The nurse cares for a school age child diagnosed with separation anxiety. What symptoms of this condition will the nurse identify for the child's parents?"
1). <b>Excessive worry</b><div><div>With separation anxiety disorder, the child may fixate on concerns about the safety of the parents that manifests as unreasonable.</div></div><div>2). <b>Reports of head or stomach aches</b></div><div><div>Somatic complaints are common and may be actual somatic manifestations of anxiety used as attempts to avoid being away from the parent.</div></div><div>3). <b>School avoidance</b></div><div><div>The child may try to find ways to avoid being separated from the parent by avoiding going to school.</div></div>
The nurse cares for a client with post-traumatic stress disorder (PTSD). What interventions does the nurse include?
1). <b>Help the client establish predictable daily routines.</b><div><div>- The nurse needs to create a safe and predictable environment to help the client feel secure while working on the anxiety related to the trauma. </div></div><div>2). <b>Educate the client on sleep hygiene practice.</b></div><div><div>- Insomnia and sleep disturbance is a frequent problem for the client with PTSD. Sleep hygiene is a term that refers to the conditions and practices that promote continuous and effective sleep.</div></div><div>3). <b>Encourage the client to engage in support groups.</b></div><div><div>- Group work is recommended for clients with PTSD.</div></div>
The client admitted after a suicide attempt requires a suicide prevention contract. The nurse collaborates with which people in writing the suicide prevention contract for the client?
1). Counselor.<br>2). Health care provider.<br>3). Client.
A nurse cares for a client diagnosed with <u>schizoaffective disorder</u>. The nurse assesses for what signs or symptoms typical of this disorder?
1). Depressed mood.<br>2). Manic episodes.<br>3). Hallucinations. 3.2 a client has level of potassium The
A nurse provides instructions to a client taking tranylcypromine (MAOI). The nurse teaches the client to avoid which foods?
1). Foods high in tyramine.<br>2). Caffeine.<br>3). Alcohol.
The nurse cares for a client at risk for alcohol withdrawal. What assessments does the nurse complete to identify physical effects of acute alcohol withdrawal?
1). Temperature.<br>2). Blood Pressure.<br>3). Blood Glucose.<br>4). Fluid balance.
The nurse cares for a client with a phobia of being alone. What actions does the nurse incorporate into the plan of care?
1). <b>Have the client verbalize the worst-case scenario that could develop if left alone.</b><br>2. <b>Encourage the client to make a list of strengths that can be applied to combat anxiety.</b><br>3). <b>Assess level of anxiety and administer prescribed antianxiety agent PRN.</b><div><div>- Appropriate use of pharmacotherapy reduces anxiety and allows the client to use coping skills.</div></div>
A client is diagnosed with Alzheimer disease. The nurse advocates for the addition of which medication?<br>1). Atorvastatin.<br>2). Donepezil.<br>3). Lorazepam.<br>4). Haloperidol.
<div><b>Donepezil</b><br></div><div><div>- Donepezil is a cholinesterase inhibitor used to treat Alzheimer disease.</div></div> 3.2 a client has level of potassium The
"A client has been started on valproic acid for the treatment of seizure disorder. Which client statement makes the nurse question the health care provider's prescription?<br>1). ""I am working to become pregnant.""<br>2). ""I get strep throat a couple of times each year.""<br>3). ""I have diabetes that I Treat with diet and exercise.""<br>4). ""I frequently experience headaches."""
<div><div><b>"I am working to become pregnant."</b></div></div><div><div>- Valproic acid has been linked to birth defects.</div></div> 3.2 a client has level of potassium The
"A client is prescribed <u>diazepam</u>. The nurse provides additional teaching when the client makes which statement?<br>1). ""This medication can be used to treat seizures.""<br>2). ""This medication will relax my muscles.""<br>3). ""This medication prevents high blood pressure.<br>4). ""This medication reduces feelings of anxiety."""
<div><div><b>"This medication prevents high blood pressure."</b></div></div><div><div>- Diazepam (Valium) can cause hypotension and is not used to prevent or treat hypertension.</div></div> 3.2 a client has level of potassium The
A client on a psychiatric unit with a panic disorder approaches a nurse in the hallway reporting anxiety, dizziness, palpitations, and shortness of breath. Which nursing actions will best help this client?
<div><div><b>1). Guide the client through a relaxation technique.</b></div></div><div><div>- Relaxation techniques or guided imagery may help the client cope until a panic attack subsides. The nurse promotes healthy coping during a panic attack.</div></div><div><div><div>2). <b>Take the client to a quiet area on psychiatric unit.</b></div></div><div><div>- Decreasing stimulation by bringing the client to a quiet area may help the client cope with the panic attack. Some clients become more anxious in social situations and do not like others staring at them during a panic attack.</div></div></div><div>3). <b>Encourage the client to exercise after anxiety subsides.</b></div><div><div>- Exercising 30 minutes daily is shown to increase brain-derived neurotrophic factor (BDNF), a chemical in the brain associated with decreasing anxiety. Physical exercise may help decrease the frequency and duration of panic attacks for certain clients.</div></div>
The nurse works on a psychiatric unit. What client does the nurse anticipate as most likely to experience delusions of grandeur (Think too highly of themselves [celebrity, richer, smarter, more famous, etc])?
<div><div><b>A client in the manic phase of bipolar I disorder</b></div></div><div><div>- The client with mania is the most likely of those listed to exhibit beliefs of inflated self that meet the criteria for delusional thinking.</div></div>
The nurse cares for a client with a personality disorder. What aspect common to personality disorders will the nurse accommodate for when creating a plan of care?
<div><div><b>Lack of insight and accountability leads to blaming others for clients with a personality disorder.</b></div></div><div><div>- Lack of insight is common for clients with personality disorders and makes treatment challenging.</div></div>
A client taking a monoamine oxidase inhibitor (MAOI) has a blood pressure of 184/122 mmHg. The client is otherwise asymptomatic. Following facility protocol, which is the most appropriate nursing action?
<div><div><b>Prepare an injectable antihypertensive drug.</b></div></div><div><div>- During a hypertensive crisis, the nurse should administer a fast-acting, injectable antihypertensive drug that directly vasodilates, such as phentolamine, nitroprusside, or labetalol. There is often an exisiting nursing protocol for this so that the nurse does not have to contact the health care provider.</div></div>
The nurse cares for a client reporting paralysis of both legs. The client is diagnosed with <b>conversion</b> disorder. Which nursing intervention does the nurse implement?
<div><div><b>Teach client deep breathing techniques for relaxation.</b></div></div><div><div> - The physical symptoms of conversion disorder are often associated with stress. Teaching the client ways to manage stress, such as deep breathing and mild exercise, provides the client with knowledge of alternate coping strategies.</div></div>
The nurse educates a client with newly diagnosed diabetes about diabetes self-management. The client demonstrates the cognitive domain of learning by which action?
<div><div><b>The client accurately states pre-meal blood sugar goals.</b></div></div><div><div>- Recognizing pre-meal blood sugar goals is an example of cognitive learning. In cognitive learning, the client acquires knowledge and intellectual skills. Cognitive behaviors include remembering and recalling facts, understanding new material, applying material in situations, and analyzing information.</div></div>
The nurse cares for a client with alcohol use disorder. The client has had multiple relapses and recently started a medication that induces nausea, vomiting, and headache <u>when alcohol is ingested</u>. This is an example of which type of therapy?
<div><div><b>The client is undergoing aversion therapy.</b></div></div><div><div>- Aversion therapy is a behavioral therapy. It pairs a negative stimulus with a specific behavior in an attempt to suppress the behavior. Aversion therapy is used when other less drastic measures have failed to produce desired effects.</div></div>
The nurse cares for a client with a history of malingering. The nurse documents what behavior as supporting evidence of malingering?<br>1). Client reports pain that cannot be explained or supported by any physical evidence.<br>2). The client only displays discomfort when there are other persons in the room.<br>3). Client is very dramatic in the reports of discomfort, being loud and demonstrative.<br>4). The client stops all reports of discomfort once the requested treatment is administered.
<div><div><b>The client only displays discomfort when there are other persons in the room.</b></div></div><div><div>- In malingering there is a conscious effort to deceive, so observing the client purposefully display symptoms only when being observed by others does help support a case for malingering, though would not be conclusive.</div></div> 3.2 a client has level of potassium The
A nurse cares for a client whose medication list includes medications for anxiety and depression. The nurse teaches the client that which drug can cause the <strong>most</strong> severe toxicity when taken incorrectly?<br>1). Lorazepam.<br>2). Nortriptyline.<br>3). Fluoxetine.<br>4). Haloperidol.
Nortriptyline.<br>- Nortriptyline is a tricyclic-antidepressant, which have been known to be fatal in overdose due to their narrow therapeutic index.
