Psych HESI

The nurse documents that a client diagnosed with stage 3 Alzheimer's disease presents with aphasia. Which client behavior supports this finding? The client is no longer able to speak. The client cannot recognize pictures of family members. The client has lost the ability to walk. The client cannot recall where personal items are located.

The client is no longer able to speak.

A health care provider informs family members that their grandfather has a reversible form of dementia. Which condition is associated with reversible dementia? HIV infection. Parkinson's disease. Fluid and electrolyte imbalance. Vascular disease.

Fluid and electrolyte imbalance.

The nurse is caring for a victim of severe emotional violence inflicted by her husband. The client states that the abuse occurs most often when her husband is intoxicated, and that he is always remorseful afterwards. She also tells the nurse that her husband's father was an alcoholic who beat him and his mother. What evidence exists that the husband is at risk of becoming a perpetrator of physical abuse? Past childhood abuse. Feelings of remorse. Temporary behavioral changes. Excessive alcohol consumption.

Past childhood abuse.

The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client? Providing nonjudgmental care. Conveying outrage that this occurred. Sympathizing with the client's sense of shame. Encouraging the client to divulge all the details

Providing nonjudgmental care.

In which age groups is depression often often underdiagnosed? Children. Adolescents. Young adults. Middle aged adults. Older adults.

Children. Adolescents. Older adults.

Which assessment data supports a diagnosis of acrophobia? Refuses to drive or walk across any type of bridge. Avoids leaving the house for more than an hour. Refuses to go outside to watch baseball even though he loves the sport. Avoids basements due to a fear of encountering spiders.

Refuses to drive or walk across any type of bridge.

A client who is experiencing tremendous stress and anxiety while being admitted to a drug detoxication facility asks the nurse, "Do you think saying a prayer would help?" Which response by the nurse is best? "To be honest, prayer may be the best way to help you cope." "You may find that prayer gives comfort and lowers your stress." "I could help you feel calmer by teaching you to meditate." "Guided imagery could be an effective alternative."

"You may find that prayer gives comfort and lowers your stress."

A student nurse working as an aide in a memory care facility asks the charge nurse if there is a neurobiological basis for the deterioration in cognitive function in Alzheimer's disease. Which explanation by the nurse is correct regarding the etiology of neurocognitive decline? "Decreases in neurotransmitters affect parts of the brain responsible for memory." "A decrease in body mass causes a decrease in the mass of the brain." "Untreated psychological problems slow down the thinking and reasoning processes." "Nutritional deficiencies cause a decrease in metabolism that inhibits the amount of glucose available to the brain."

Decreases in neurotransmitters affect parts of the brain responsible for memory."

The health care provider is performing a follow-up exam on a 17-year-old-client who was raped six months ago. The client states that she completed counseling and has been feeling like she is starting to put the experience behind her. Which action by the client is a sign of recovery? Going to her senior prom with her boyfriend. Taking sertraline (Zoloft) for anxiety. Expressing a need for more counseling. Refusing to go out alone in public.

Going to her senior prom with her boyfriend.

Failure to keep medical appointments, arriving late, and being non-compliant with prescribed medications are common behaviors exhibited by clients with personality disorders. Which intervention should be incorporated into the plan of care when a client demonstrates any of these behaviors? Designate a staff member to be responsible for imposing compliance with treatments and appointments. Include the client in the decision-making process regarding treatments and appointments. Designate a family member to help the client remain compliant with treatments and appointments. Restrict privileges until the client demonstrates compliance with treatments and appointments.

Include the client in the decision-making process regarding treatments and appointments.

The family and friends of a client with a heroin addiction are planning an intervention meeting to convince the client to seek help. Which strategy should the group employ to help ensure a successful intervention? Make notes on what to say to the client and rehearse before the meeting. Attempt the intervention at a time when the client is under the influence. Stage the intervention in a public place that is familiar to the client. Set boundaries and be prepared to act in case the client behaves defensively.

Make notes on what to say to the client and rehearse before the meeting.

What are some of the family risk factors the nurse should look for when interviewing a client who is suspected of being in an abusive relationship? Mental health problems in the nuclear family.. Substance abuse by household members. Family relationships that appear dysfunctional. The ethnic and cultural background of the family. Educational background of client and family members.

Mental health problems in the nuclear family.. Substance abuse by household members. Family relationships that appear dysfunctional.

The nurse is interviewing a newly admitted client with major depression. Which statement by the client is evidence of a genetic etiology of this mood disorder? My mother was diagnosed with bipolar affective disorder. My uncle was diagnosed with schizophrenia. My cousin was hospitalized with suicidal ideation last year. My niece is being evaluated for borderline personality disorder.

My mother was diagnosed with bipolar affective disorder.

The nurse is caring for a client diagnosed with a personality disorder. The client states that he must constantly fend off females who seek his attention. He boasts that he is a former high school baseball player who was once voted most valuable player, and he claims that no other baseball player will ever be as good as he was in baseball and he should play professionally, but his salary would be too high for the professioal leagues to pay him. These statements reflect which personality disorder? Narcissistic personality disorder. Obsessive-compulsive disorder. Histrionic personality disorder. Borderline personality disorder.

Narcissistic personality disorder.

A client is undergoing treatment for schizophrenia. Which outcome provides evidence that the client's negative symptoms are improving? Refrains from yelling and trying to touch the health care provider for the last 48 hours. Participates in music therapy and states that he enjoys playing the drums. Eats meals in his room instead of causing disturbances during mealtime. Reports having no hallucinations for the last week.

Participates in music therapy and states that he enjoys playing the drums..

A client with stage 2 Alzheimer's disease is being cared for at home by the spouse. The client's spouse tells the nurse about the emotional difficulties involved in providing fulltime care at home. Which self-care activity is most important for the nurse to recommend to the spouse? Periodic times of respite from caregiving. Regular attendance at church services. Participation in reminiscence therapy. Establishment of a predictable daily schedule.

Periodic times of respite from caregiving. Rationale Caregiver role strain may be attributed to many different factors. The nurse must become familiar with this diagnosis in order to accurately assess the caregiver and offer effective interventions. One important recommendation is to have the caregiver incorporate periodic breaks as part of the daily routine to relieve stress. The nurse should contact the client's manager and provide the client's caregiver a list of agencies offering "Respite Care".

The nurse notes that a client is experiencing panic-level anxiety during a group meeting in the community room. Which intervention should be implemented immediately? Provide calm, brief, and directive communication. Administer anxiolytic medication, as ordered. Teach the client relaxation techniques. Prepare staff members to restrain the client.

Provide calm, brief, and directive communication. Rationale Clients experiencing severe- to panic-level anxiety often feel out of control and need to know they are safe from their own impulses. This can be achieved through firm, short, and simple statements. Reinforcing commonalities in the environment and pointing out reality when there are distortions can also be useful when caring for a severely anxious client.

The nurse is providing care to a client suspected of Munchausen. The nurse should understand that which example demonstrates a breach of a client's constitutional right to privacy? Releasing information to the client's employer without consent. Discussing the client's history with other staff during care planning. Documenting the client's daily behaviors during hospitalization. Asking the family to share information about the client's behavior before hospitalization.

Releasing information to the client's employer without consent.

Which nursing diagnosis is the priority for a client who is being treated with lithium? Risk for Infection. Self-care deficit. Risk for fluid imbalance. Nutritional deficit.

Risk for fluid imbalance.

The nurse is performing a pre-op assessment on an 18-month-old client who is scheduled for minor surgery. The nurse observes numerous bruises of different stages over the client's back and buttocks. The mother states that the child must have fallen down while playing alone outside, but she does not provide any specific information. Which statement regarding the assessment data should the nurse enter into the electronic medical record? Suspected child abuse and neglect. Immature parenting. Normal findings in an 18-month-old. Indications of tissue fragility.

Suspected child abuse and neglect.

The nurse is performing a pre-op assessment on an 18-month-old client who is scheduled for minor surgery. The nurse observes numerous bruises of different stages over the client's back and buttocks. The mother states that the child must have fallen down while playing alone outside, but she does not provide any specific information. Which statement regarding the assessment data should the nurse enter into the electronic medical record? Suspected child abuse and neglect. Immature parenting. Normal findings in an 18-month-old. Indications of tissue fragility.

Suspected child abuse and neglect.

The visiting nurse is assessing a client with early-stage dementia who has recently been prescribed donepezil (Aricept). Which information obtained from the client's family member demonstrates that the medication is effective? The client is showering and getting dressed with minimal assistance. The client uses confabulation to cover up memory loss. The client did not attend the family reunion last weekend. The client arranges to have groceries delivered.

The client is showering and getting dressed with minimal assistance.

A client with delirium keeps attempting to get out of bed and has fallen twice, despite being under close-observation. The charge nurse calls the health care provider to obtain an order for mechanical restraints. Which statement is correct regarding the mechanical restraint policy? The client will need to remain on close-observation with a documentation note every 15 minutes. The client no longer require close-observation, but must be checked at regular intervals. The client may be sedated and left alone as long as the restraints remain in place. Restraints may be applied based on verbal orders received over the phone.

The client will need to remain on close-observation with a documentation note every 15 minutes.

The nurse is educating a new staff member about the causes of personality disorders. The nurse is correct to identify which causes? Abnormal brain structure and disturbances involving serotonin and GABA. Abnormal brain structure and disturbances involving dopamine and GABA. Nutrition al deficiencies and damage to the brain stem. Nutritional deficiencies and damage to the limbic system.

Abnormal brain structure and disturbances involving serotonin and GABA.

A client who compulsively performs handwashing rituals throughout the day is being treated for obsessive compulsive disorder (OCD). Which behavior change indicates that treatment has been effective? Arrives at the dining hall on time for every meal for the last 2 days. Exhibits good hygiene habits for the last week. Reads educational material regarding his illness. Begins to wash the floors after returning from outside excursions.

Arrives at the dining hall on time for every meal for the last 2 days.

During a follow-up visit to the mental health clinic, the mother of a 7-year-old client reports that her son has been having side effects from the medication that was ordered to treat ADHD. The mother states that the client has a decreased appetite, complains of abdominal pain, and has been unable to sleep. The health care provider recommends that the medication be changed to a nonstimulant ADHD drug. Which medication should be recommended for this client? Atomoxetine (Strattera). Methylphenidate (Ritalin). Fluphenazine (Prolixin). Fluoxetine (Prozac).

Atomoxetine (Strattera).

A client was admitted to the inpatient unit 48 hours ago with a diagnosis of a Cluster "C" personality disorder. The client is well rested, but refuses to attend meals or group sessions. The client has been started on a SSRI for anxiety but has not demonstrated an effective response. Which other category of anxiolytic medication may be prescribed to produce a more immediate decrease in symptoms? MAOIs. Benzodiazepines. Lithium salts. Psychotropic medications.

Benzodiazepines.

An interdisciplinary treatment team meets to discuss a client diagnosed with paranoid schizophrenia and cannabis abuse who is experiencing increased hallucinations and delusions. How should the team plan an effective treatment? Consider each diagnosis primary and provide simultaneous treatment. Treat the schizophrenia before establishing goals for substance abuse treatment. Withdraw the client from cannabis before treating the symptoms of schizophrenia. Hospitalize the client for the longest possible stay that insurance will allow.

Consider each diagnosis primary and provide simultaneous treatment. Rationale Clients with dual or co-occurring diagnoses, such as a substance use disorder with a psychiatric disorder, should be treated for both conditions simultaneously. They are both considered a primary diagnosis and need to be addressed for treatment to be effective.

An 85-year-old client is bought to the emergency department after a fall at home. The client appears confused, malnourished, and is severely dehydrated. The client appears reluctant to explain how the fall happened. The client's daughter speaks for the client and does not allow the client to answer questions. Based on this information, which nursing intervention is a priority? Interview the client alone and assess for abuse. Take the history from the daughter because the client is confused. Provide the daughter with nutritional counseling. Request a psychiatric evaluation for the client.

Interview the client alone and assess for abuse.

The psychiatric clinical nurse specialist decides to use cognitive behavioral therapy (CBT) techniques as she works with a bulimic client. Which statement by the nurse is an example of the application of cognitive behavioral therapy principles? "Being thin does not seem to solve your problems; you are thin now and still unhappy." "What are your feelings about not eating the food that you prepare for others?" "You seem to feel much better about yourself when you eat something." "Is it difficult to talk about your feelings and private matters with someone you've just met?"

"Being thin does not seem to solve your problems; you are thin now and still unhappy."

During a meeting with the interdisciplinary treatment team, a client in the acute phase of schizophrenia states that she cannot return to live with her parents because they are trying to kill her. Which statement by the team leader represents a correct therapeutic response? "We met with your parents; they do not appear to be violent people." "You are having a delusion; your parents would never hurt you." "That must be very frightening; tell us why you believe you are in danger." "You are being paranoid; your parents referred you here so that you can be helped."

"That must be very frightening; tell us why you believe you are in danger."

A client seeks assistance at a crisis center. The client describes being extremely anxious and unable to sleep since helping with clean-up duties at a school where a student fatally shot a teacher and some classmates. Which intervention is the priority when assisting this client? Allow ventilation of feelings. Refer the client to a member of the clergy. Advise the client to avoid going near the school for at least six weeks. Send the client to an emergency department for further evaluation.

Allow ventilation of feelings.

The nurse is planning a community education program about childhood mental health problems that appear to be genetically transmitted. While conducting the program, which problem should the nurse emphasize? Autistic disorders. Sleepwalking. Anxiety states. Conduct disorder.

Autistic disorders. Rationale Researchers have discovered several sporadic genetic mutations in children with autism spectrum disorder (ASD). A program that focuses on childhood mental health disorders that have a possible genetic link should include information about ASD.

The nurse is interviewing a client who has recently been admitted for evaluation of a thought disorder manifested by paranoid behavior. According to the client's mother, the client was previously treated for anxiety, but has become more isolated and withdrawn over the last few weeks. He refuses to leave his room, and he states that he is the "King of Mars" and someone is trying to assassinate him. Which type of delusion should the nurse document? Jealous. Grandiose. Somatic. Erotomanic.

Grandiose.

The nurse is caring for a 72-year-old client who was admitted for treatment of depression. The nurse notices that the health care provider's order for an antidepressant calls for a dose greater than the usual adult dose. Which action is the correct action for the nurse to take? Hold the medication and consult the health care provider. Check the electronic formulary on the unit's computer. Give the usual adult dose. Implement the order as prescribed.

Hold the medication and consult the health care provider.

A health care provider prescribed donepezil (Aricept), for a client newly diagnosed with early-stage dementia. The client asks the nurse, how the medication is going to slow down the process of memory impairment. Which explanation by the nurse is accurate regarding the purpose of this medication? It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses. It acts as a sleep aid to address sleep difficulties that may accelerate dementia. It decreases the circulation of calcium in the cardiovascular system, which is responsible for memory loss. It increases the amount of glucose available to the brain to maintain current brain function.

It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses.

During a homecare visit, the nurse is assessing an elderly client diagnosed with bipolar depression who lives alone. The client appears disheveled and is wearing slippers on the wrong feet. The nurse observes various throw rugs, old food containers, and other trash scattered throughout the house. No smoke detectors are visible. The client is unable to recall the date or time of year and not able to have a coherent conversation. Which nursing diagnosis is the priority concern? Risk for injury. Self-care deficit. Nutritional deficit. Risk for depression.

Risk for injury. Rationale Safety is always the primary concern when assessing a client. Other nursing diagnoses may need to be addressed, but only after safety needs are met. Information provided in this example includes several factors that contribute to the client's risk for injury (e.g., cognitive decline, trip hazards, etc.).

The nurse is providing information about codependent behaviors to the wife of a client with alcoholism. The nurse is correct to identify and point out to the wife which behavior as an example of codependency? She calls in sick for her husband when he is too hung over to work. She prepares dinner for her husband every night. She shops for all her husband's clothes. She frequently drives her husband to work.

She calls in sick for her husband when he is too hung over to work.

The nurse is providing information about codependent behaviors to the wife of a client with alcoholism. The nurse is correct to identify and point out to the wife which behavior as an example of codependency? She calls in sick for her husband when he is too hung over to work. She prepares dinner for her husband every night. She shops for all her husband's clothes. She frequently drives her husband to work.

She calls in sick for her husband when he is too hung over to work.

A client with schizophrenia is attending group therapy sessions. Which actions by the client demonstrate that he is progressing to the stabilizing phase of illness? The client participates and attempts to convince others that his delusions are real. The client admits to past delusions but states that he is a rock star who no longer needs group therapy. The client participates and states that his delusions are not real, but that he needs them to feel better. The client denies having delusions but states that he writes to government officials to report his spy activities.

The client participates and states that his delusions are not real, but that he needs them to feel better.

The nurse is counseling a client who is dealing with complicated grief over the death of a spouse. Which statement reflects the most desirable outcome for the client? The client will attend a surviving spousal support groups. The client will plan a memorial tribute for the spouse. The client will stop expressing feelings of loss every day. The client will plan a vacation after finalizing the burial arrangements.

The client will attend a surviving spousal support groups.

The interdisciplinary treatment team is designing a plan for a client with antisocial personality. The client's behaviors include lying to other clients, flattering the primary nurse, verbally abusing a client who has Alzheimer's disease, and being argumentative at counseling sessions. Which behavior is the priority for the treatment team to address? Verbal abuse of another client. Lying to the other clients. Flattering his primary nurse. Arguing during counseling sessions.

Verbal abuse of another client.

The nurse is teaching a group parents and teachers about preventing substance abuse in children. What practices during childhood are known to minimize substance abuse later in life? Adults who teach and display self-control behaviors in difficult situations. Encouraging and praising academic achievement. A strong sense of community and neighborhood attachment. Parents who are involved and monitor their children's daily lives. Implementing strict rules with severe yet consistent consequences.

Adults who teach and display self-control behaviors in difficult situations. Encouraging and praising academic achievement. A strong sense of community and neighborhood attachment. Parents who are involved and monitor their children's daily lives.

A client with long-term alcohol addiction is admitted to the emergency department. Which medications should the nurse anticipate the healthcare provider will prescribe for this client? Diazepam. Methadone. Multivitamins. Thiamine (vitamin B1). Monoamine oxidase inhibitors.

Diazepam. Multivitamins. Thiamine (vitamin B1).

The health care provider is evaluating a client with bulimia who is being treated with fluoxetine (Prozac), a selective serotonin reuptake inhibitor. It is determined that medication has been ineffective because the client's mood and obsessive compulsive behaviors have not improved. Which unconventional antipsychotic agent should the health care provider recommend for the client? Olanzapine (Zyprexa). Sertraline (Zoloft). Lorazepam (Ativan). Zolpidem (Ambien).

Olanzapine (Zyprexa). Rationale Olanzapine (Zyprexa) is an unconventional antipsychotic agent used to treat some mental disorders. It has proven successful in some clients by decreasing compulsions and improving mood.

The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client? Providing nonjudgmental care. Conveying outrage that this occurred. Sympathizing with the client's sense of shame. Encouraging the client to divulge all the details

Providing nonjudgmental care.

The spouse of a client who was admitted to an alcohol detox center is attending an AL-ANON meeting. The spouse asks the group leader if their children could inherit the tendency for alcohol addiction. Which is a correct response by the group leader? "Children of alcoholics are three times more likely to inherit the disease than children of non-alcoholic parents." "Current studies are being conducted to investigate heredity as a factor, but unfortunately there has been no progress." "There are no genetics involved; alcohol abuse and addictions are learned behaviors." "Genetics have a minor effect, but if you educate your children about the dangers of drinking, they should be OK."

"Children of alcoholics are three times more likely to inherit the disease than children of non-alcoholic parents."

A universal outcome for victims of rape is grief resolution. Which statement by the victim indicates that progress toward this outcome has been made? "I have begun to stop blaming myself for being raped." "If I had not worn that skirt to the party, the rape would not have happened." "I need to make sure that I do not go out alone anymore." "I feel ashamed that I could not defend myself against my attacker."

"I have begun to stop blaming myself for being raped."

The nurse is providing counseling to a client about recovery from alcoholism. Which client statement indicates that learning has occurred? "Once I have detoxed, my recovery is complete." "I realize that recovery is a lifelong process that occurs in steps." "I understand that the goal of the program is to decrease my drinking." "I will only drink beer because hard liquor has a higher alcohol content."

"I realize that recovery is a lifelong process that occurs in steps."

A client diagnosed with obsessive-compulsive personality disorder with a comorbid depression has been receiving dialectic behavior therapy (DBT). Which statement by the client indicates that the treatment has been effective? "Yoga and deep breathing help me when I get anxious about upcoming family visits." "I can feel my heart pounding when I practice deep breathing and it gives me a headache." "Listening to relaxing music reminds me of my ex-husband and how I messed up our marriage." "I feel like I can become a movie star after I finish my meditation and exercise sessions."

"Yoga and deep breathing help me when I get anxious about upcoming family visits."

A client has recently been admitted for evaluation of sudden onset psychosis. In addition to a medical assessment and serum drug screen, which other tests should the nurse expect the client will undergo to find a cause for this change in mental status? Brain MRI, PET scan. Skull radiographs, free thyroxin. CT angiography, electromyogram. Carotid Doppler, electrocardiogram.

Brain MRI, PET scan.

Which behaviors indicate that the treatment plan for a client in alcohol rehabilitation has been effective? Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. Abstinent 15 days; states that the drinking problem has been overcome; plans to find a new line of work with new coworkers. Attends Alcoholics Anonymous daily; states that many of the members are real alcoholics; denies having any problems at work. Attends Alcoholics Anonymous once per week; states a willingness to stop drinking during the day; plans to drink occasionally after work.

Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. Rationale The statement "one day at a time" reflects the Alcoholics Anonymous (AA) philosophy. AA promotes a 12-step program that has been successful in helping individuals who desire to stop drinking and abusing substances. Individuals learn about sobriety and responsibility through the support of other members.

A client has recently been admitted for evaluation of sudden onset psychosis. In addition to a medical assessment and serum drug screen, which other tests should the nurse expect the client will undergo to find a cause for this change in mental status? Brain MRI, PET scan. Skull radiographs, free thyroxin. CT angiography, electromyogram. Carotid Doppler, electrocardiogram.

Brain MRI, PET scan.

The sibling of a young client with borderline personality disorder asks the nurse why the client has frequent mood changes. Which is the best response by the nurse to explain the neurobiological basis of this behavior? Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions. Shifts in mood are the result of an intolerance to certain chemicals found in food substances. Mood changes are due to the client's emotional immaturity and lack of insight into this behavior. Mood changes are common in clients during this phase of life due to hormonal changes.

Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions.

The community health nurse is teaching a class of high school students about bullying. One of the students asks about social factors that might contribute to violent behavior. Which response by the nurse is correct? Children consuming too much sugar have a tendency to become violent. Children can learn aggressive behaviors by observing violence in the home. Individuals who are raised in poor families usually become violent. Children of overprotective parents usually develop aggressive behaviors.

Children can learn aggressive behaviors by observing violence in the home.

A client is admitted due to alcohol intoxication and injuries sustained in a fall. The client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140 and a blood pressure of 170/98. Delirium is suspected due to the client's claim that bugs are crawling on the bed. Which medication should the nurse expect will be administered to the client? Chlordiazepoxide (Librium). Disulfiram (Antabuse). Acamprosate calcium (Campral). Mesalamine (Asacol HD).

Chlordiazepoxide (Librium).

The nurse is caring for a client who has delusions of infidelity. The client's wife asks if there is any circumstance under which the treatment team is justified in violating the client's right to confidentiality. Which response is correct regarding exceptions to the client's right to confidentiality? Confidentiality is waived if the client threatens the life of another person. Confidentiality is waived when law enforcement requests information. Confidentiality is waived only at the discretion of the psychiatrist. Confidentiality is to be maintained without exception.

Confidentiality is waived if the client threatens the life of another person. Rationale The duty to warn a person whose life has been threatened by a psychiatric client overrides the client's right to confidentiality. It is the legal responsibility of any health care personnel, the duty to warn when an individual threatens to harm or hurt themselves or another individual.

A client with stage 3 Alzheimer's disease is admitted to a behavioral health hospital. Due to the progression of the disease, the client is experiencing an increase in amnesia and agnosia, and has declined to the point of not recognizing familiar objects and people. Which action should the nurse take to help reduce the client's fear and anxiety and adjust to the new setting? Cover mirrors and pictures if they are upsetting the client. Keep the TV on in the room throughout the day. Provide the client with a stuffed animal. Serve the client's meals in a private room.

Cover mirrors and pictures if they are upsetting the client.

The nurse is reviewing labs for a client who is taking clozapine, 25mg QD for treatment of disorganized schizophrenia. The labs are documented as follows: RBC 4.5 million/mcL, WBC 1000/mcL, TSH 1.2 mc-IU. Based on these results, which order should the nurse anticipate the health care provider to write? Discontinue clozapine. Administer levothyroxine sodium 25 mcg QD. Administer ferrous sulfate 100mg QD. Decrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg QD.

Discontinue clozapine. Rationale Agranulocytosis is an adverse side effect of clozapine that can cause lethal infections. Based on the client's results, clozapine should be discontinued; the thyroid and RBC results are normal and do not need to be treated.

he nurse is interacting with the spouse of a client being treated for substance abuse. During the interview, the spouse makes excuses and takes the blame for the client's actions. Which terms best describe the spouse's behavior? Loyal. Enabling. Tolerance. Antagonistic. Co-dependency.

Enabling. Co-dependency. Rationale Individual's who enable another or create a co-dependent relationship often enjoy the feeling of being needed.

Which elements have been shown to be beneficial when incorporated into a stress management plan? Retreating from friends. Exercise. Mindfulness practices. Social media. Balanced diet.

Exercise. Mindfulness practices. Balanced diet. Rationale Sleep is essential to engage in activities of daily living. Exercise has been found to decrease stress levels and cortisol levels and increase sense of well-being. Relaxation reduces psychological or physiological distress. Multitasking facilitated by technology has been identified as a significant source of stress. Well-balanced diet can facilitate stress reduction and improve physical well-being.

he interdisciplinary team is planning treatment for a client with stage 2 Alzheimer's disease. The team agrees that involving the client in more therapy groups and activities could help improve memory and relieve some depressive symptoms. The team leader recommends reminiscence therapy. Which statement Facilitates discussions of life's transitions and evokes memories from the client's past. Encourages clients to pick a topic of concern and discuss their fears. Introduces the client to new forms of recreational therapy that may improve memory. Enables clients to develop new skills based on their previous skill sets.

Facilitates discussions of life's transitions and evokes memories from the client's past.

The school nurse is providing an in-service program to high school girls about date rape drugs. A student expresses interest about particular drugs and asks the nurse what these drugs look like and how they affect the body. Which response by the nurse it correct? Flunitrazepam (Rohypnol) is a pill that dissolves in liquids and causes muscle relaxation and amnesia. Diphenhydramine (Compose) is a pill or capsule that is used to induce sleep. Acetaminophen plus ephedrine (NyQuil) comes in pill and liquid form and causes drowsiness. Cyclobenzaprine (Flexeril) comes in a pill form and causes drowsiness and relaxation.

Flunitrazepam (Rohypnol) is a pill that dissolves in liquids and causes muscle relaxation and amnesia. Rationale Flunitrazepam (Rohypnol) is a date rape pill that is also called "forget-me-not." It dissolves in water, becomes more potent when combined with alcohol, and causes relaxation and amnesia.

An addiction counselor is teaching a client and family about cross tolerance, cross addiction and alcohol, benzodiazepines, and barbiturates. The counselor is also teaching about the dangers of concurrent use. The nurse is correct to state that alcohol and CNS depressants act on which receptors? GABA. Serotonin. Dopamine. Opioid.

GABA.

Which characteristics have been associated with substance abuse? Self reflection. Grandiosity. Manipulation. Low risk taking. Dysfunctional anger.

Grandiosity. Manipulation. Dysfunctional anger.

The nurse is caring for a 72-year-old client who was admitted for treatment of depression. The nurse notices that the health care provider's order for an antidepressant calls for a dose greater than the usual adult dose. Which action is the correct action for the nurse to take? Hold the medication and consult the health care provider. Check the electronic formulary on the unit's computer. Give the usual adult dose. Implement the order as prescribed.

Hold the medication and consult the health care provider.

The treatment team is reviewing the plan of care for a client diagnosed with borderline personality disorder. The client has been acting out during group meetings and creating conflict between staff members. Which interventions by the staff will be most effective to decrease the behavior of "splitting" the staff? Increase frequency of staff meetings to discuss concerns and plan strategies. Designate one staff member to work with the client. Plan a meeting with the client's family to discuss the client's disruptive behavior. Exclude the client from attending groups until the behavior improves.

Increase frequency of staff meetings to discuss concerns and plan strategies.

The nurse is providing discharge education for a client prescribed a tricyclic antidepressant. Which statement by the client indicates the need for additional teaching? "It is best for me to take the full dose of the medication when I get up each morning." "My mood should improve within 7-28 days after starting my medicine." "It may take up to 6-8 weeks for me to experience the full effect of the medication." "The side effects of drowsiness and dizziness usually go away after the first few weeks."

It is best for me to take the full dose of the medication when I get up each morning." Rationale If possible, the client should take the full dose of tricyclic antidepressants at bedtime to reduce the experience of side effects during the day.

A health care provider prescribed donepezil (Aricept), for a client newly diagnosed with early-stage dementia. The client asks the nurse, how the medication is going to slow down the process of memory impairment. Which explanation by the nurse is accurate regarding the purpose of this medication? It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses. It acts as a sleep aid to address sleep difficulties that may accelerate dementia. It decreases the circulation of calcium in the cardiovascular system, which is responsible for memory loss. It increases the amount of glucose available to the brain to maintain current brain function.

It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses.

The treatment team discusses plans regarding two clients who both exhibit self-mutilating behavior. The nurse expresses concerns about the decision to use restraints on one client, while assigning one-to-one supervision for the other. Which ethical principal is the nurse concerned about violating? Justice. Autonomy. Beneficence. Fidelity.

Justice.

The spouse of a heroin addict asks the nurse, "What is methadone maintenance all about?" Which response by the nurse is correct? Methadone reduces cravings and blocks the action of opiates. Methadone reduces craving without any sedative effects. Methadone is less potent than other replacement drugs. Methadone is a deterrent to the use of both "hard" and "soft" drugs.

Methadone reduces cravings and blocks the action of opiates.

An adolescent client was recently admitted to the eating disorder unit and is complaining of severe muscle aches, fatigue, and weakness. The nurse completes a physical assessment and reviews the client's most recent lab results. All lab values are within normal limits except the potassium level, which is 2.7 meq/L. Based on this assessment, which nursing intervention is the priority? Notify the health care provider that the client is hypokalemic and complaining of muscle aches. Medicate the client with cyclobenzaprine 5mg every 8 hours PRN for muscle aches. Encourage the client to take a hot shower to relieve aches and pains. Assess the client's pain and administer pain medication as ordered.

Notify the health care provider that the client is hypokalemic and complaining of muscle aches.

During a home care visit for a client diagnosed with schizophrenia, the spouse complains to the nurse that the client is refusing to eat or drink anything that is prepared for them. Which intervention should the nurse recommend? Instruct the caregiver to place the prepared food next to the client and leave the room. Teach the caregiver how to gentle force feed the client with soft mechanical diet. Recommend that unopened, prepackaged food to be given to the client. Suggest that a tube feeding nutrition therapy be initiated.

Recommend that unopened, prepackaged food to be given to the client. Rationale Clients diagnosed with schizophrenia can experience periods of paranoia and this client may believe their food has been tampered and posioned. Offering the client prepackaged food that has not been open, may be the only alternative to get the client to eat and drink.

A client is admitted to the medical unit with needle tracks on both arms. A friend has stated that the client uses heroin. The nurse should recognize which group of signs and symptoms in clients suffering from opioid withdrawal? Runny nose, yawning, insomnia, and chills. Slurred speech, excessive drowsiness, and bradycardia. Anxiety, agitation, and aggression. Paranoid delusions, tactile hallucinations, and panic attacks.

Runny nose, yawning, insomnia, and chills.

A 5-year-old cries and screams continuously from the time their mother drops them off at kindergarten until she picks him up 4 hours later. He is calm and relaxed when he is with his mother. The mother seeks advice from a friend who is a nurse. Which response by the nurse is best? "Talk with your healthcare provider about referring him to a mental health clinic." "Talk with the school principal about withdrawing him until he is more mature." "Arrange with the teacher to let him call home during play time." "Send a picture of yourself to school to keep with him."

Talk with your healthcare provider about referring him to a mental health clinic." Rationale Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. The first evidence of this disorder often occurs when the child begins going to school, and it may be based of the child's fear that something will happen to the attachment figure. Professional help is needed to learn how to cope with anxiety effectively. Separation anxiety is common childhood condition that usually becomes evident around seven months of age, but should subside around three years of age.

The visiting nurse is assessing a client with early-stage dementia who has recently been prescribed donepezil (Aricept). Which information obtained from the client's family member demonstrates that the medication is effective? The client is showering and getting dressed with minimal assistance. The client uses confabulation to cover up memory loss. The client did not attend the family reunion last weekend. The client arranges to have groceries delivered.

The client is showering and getting dressed with minimal assistance.

The nurse is assessing a client who expresses feeling overwhelmed with the care of an elderly parent. Which question best uncovers the client's perception of this event as a stressor? Have you started drinking or smoking as a result of this stressor? What impact does this stressor have on your life? Are you having trouble getting to sleep or staying asleep? What do you believe is causing you stress right now? Who else is helping with the caregiving and household chores?

What impact does this stressor have on your life? What do you believe is causing you stress right now? Rationale A change in someone's financial status, other stressors present, and an unanticipated stress are factors that have an affect on individuals regardless of their social cultural background or age or gender.