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When attempting to establish trust and rapport with a client with schizophrenia, the priority action for the nurse would be to

make emotional contact.2

An important nursing consideration when caring for an abused older adult client is that the abused older adult

may be humiliated and defensive about abusive experiences.2

A nurse instructs a client taking a medication that is a monoamine oxidase inhibitor (MAOI) to avoid certain foods and drugs because of the risk of

hypertensive crisis.3

An older adult client states, "Life isn't so good and I'm ready to just end it all." The best approach for the nurse to take at this time would be to

initiate a no-suicide contract with the client.4

Which statement is most likely from a client with anorexia nervosa?

"I'm fat and ugly."2

A nurse interacts with a newly hospitalized client. Which of the following nursing comments applies the communication technique of "offering self."

"'I'd like to sit with you for a while to help you get comfortable talking to me."

The nurse is conducting client teaching on the topic of seizures and cocaine use. Which of the statements made by the client demonstrates knowledge of cocaine-related seizures?

"Any type of cocaine use can produce a seizure in any person."2

A client is being discharged after a mastectomy. Before leaving the hospital, she comments to the nurse, "I'll never get married now. No man would want a disfigured woman." Which response by the nurse would be most appropriate?

"Are you afraid that you won't be attractive to men now?" Submit

An older adult client is hospitalized after complaining of difficulty sleeping, extreme anxiety, shortness of breath, and feelings of dismay. What is the best response for the nurse to make?

"Can you talk about what might have happened recently that may have triggered these feelings?" Submit

A female client has a black eye and bruises about the mouth, and the nurse suspects physical abuse. Which question from the nurse would be most appropriate?

"Can you tell me what happened?"3

A client who has recently been diagnosed with end-stage lung cancer states, "I feel like I am going to die very soon." What is the nurse's best response?

"Can you tell me what makes you think you will die so soon?" Submit

When caring for a client with dementia, what nursing action is a priority?

Creating a safe environment3

The client was admitted to the psychiatric hospital with a history of increasing suspicion and hostility. During the admission interview, the client tells the nurse he knew he was followed to the hospital by spies hired by his coworkers. The nurse understands that this thinking is an example of

delusion of persecution. Submit

A client has been prescribed a benzodiazepine. The nurse knows that the most common adverse effect on the central nervous system is its action as a

depressant

A young couple are experiencing extreme anxiety after their new home was flooded due to a broken pipe. The initial nursing intervention would be to

determine what available community housing resources are available.3

A client is discharged with a prescription for lithium carbonate. Discharge teaching includes reporting signs of toxicity, which are

fine tremors and thirst.2

A nurse whose family has a history of drug abuse makes derogatory comments while caring for a substance abuse client. What might be an explanation for the nurse's behavior? The nurse

is unaware of her feelings when working with this type of client.3

A client with a diagnosis of schizophrenia, catatonic type, begins to demonstrate "waxy flexibility." What are the characteristics of this behavior? The client

keeps the arm raised long after the nurse has finished taking the blood pressure.3

A client has been on suicide precautions. The client's feelings of despair and depression are not as severe as before, and the client tells the nurse, "I feel better now." The nurse understands that this client is

more of a suicide risk than when she was deeply depressed.4

The nurse would recognize that typical nursing assessment findings in a client experiencing anxiety are

palpitations, sweaty palms, and shortness of breath. Submit

A client with acute mania has disrobed in the hall 3 times in 2 hours. How should the nurse intervene?

Maintain one-on-one supervision. Submit

Which of the following best describes binge eating?

The client has been rapidly consuming a large amount of food.4

A client is experiencing auditory hallucinations. What would the nurse be most concerned about?

How the voices are telling him to hurt someone3

A person has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" What is the nurse's most therapeutic response?

"Feeling that people want to destroy you must be very frightening."3

A client is crying and anxious and tells the nurse that her husband has recently asked her for a divorce. Which is the best response for the nurse to make?

"I can see how upset you are. Let's talk about what happened."4

Which of the following statements by a client would indicate possible low self-esteem?

"I'll never get the hang of this. I'm just too dumb, I guess."3

Which comments by a nurse demonstrate use of therapeutic communication techniques? (Select all that apply.)

"I'm glad you were able to tell me how you felt about your loss."4"I noticed your hands trembling when you told me about your accident."

A mental health client has suddenly developed an intense fear of heights. During a group therapy session, she makes the following statements: "I know my feeling of being terrified of heights is dumb. It doesn't make any sense. I just can't seem to do anything about it." Which response would be most appropriate for the nurse to make?

"Knowing that your fears don't make any sense doesn't seem to help you feel better."3

A child is brought into the emergency department with bruises and raised welts on the back. The nurse suspects child abuse. What would be the appropriate action?

Call the ER nursing supervisor for follow-up reporting. Submit

The nurse is assessing a client who may be experiencing auditory hallucinations. Which client activity would assist the nurse to confirm that a hallucination is occurring?

Client mumbling to self, tilted head, eyes darting back and forth.2

A client tells the nurse that he can't eat his dinner because the food has been poisoned. The nurse describes this behavior as an indication of which of the following?

Paranoia3

The parent of a child diagnosed with schizophrenia tearfully asks the nurse, "What could I have done differently to prevent this illness?" Select the nurse's best response.

"Schizophrenia is a biological illness resulting from changes in how the brain and nervous system function. You are not to blame for your child's illness."3

A client reports, "I am overwhelmed by stress." Which question by the nurse would be most important to use in the assessment of this the client?

"Tell me about the kinds of things you do to reduce or cope with your stress."4

A nurse is interacting with clients in a psychiatric unit. Which statements reflect use of therapeutic communication? (Select all that apply.)

"Tell me more about that situation."2 "I notice you are pacing a lot." "I'll stay with you a while."

A mental health client reports to the nurse that the television is talking to her in a threatening manner. What is the nurse's best response to the client's verbalization about the television?

"That seems unusual. Thoughts may seem confusing when one is upset or frightened." Submit

Which hallucination necessitates the nurse to implement safety measures? The client says,

"The voices say everyone is trying to kill me."3

The mother has not seen her premature baby since birth and is very distressed. Upon her first visit to the intensive care nursery, she is concerned about the feeding tube and asks if her baby will be able to eat like a normal baby. What is the best nursing response?

"This type of feeding method is usually only temporary."4

A client tells the nurse, "I don't think I'll ever be discharged for this place." What would be the most therapeutic response nursing response?

"You don't feel you're making progress?"4

The depressed client is crying; she sobs and says, "I'm so ugly and awful. Why do you come here?" The nurse's best response is

"You feel so badly about yourself today. Let's talk about it."2

The nurse is placing a diet order for the client with bipolar disorder (manic phase). Which foods would be most appropriate?

A ham and cheese sandwich, carrot and celery sticks, apple, and cookies3

A client becomes increasingly withdrawn after a mastectomy. She refuses food and asks that the curtains be kept drawn around the bed. What will be an important principle for the nurse to include in the response to the client?

Acknowledge to the client this is a difficult time and maintain contact with her.4

The nurse is caring for a client with schizophrenia, catatonic type. The client refuses to eat. What is the best nursing action?

Advise supervisor that client is not eating.3

A client receiving phenelzine sulfate must be taught to avoid which foods?

Aged cheeses, beer, and avocados3

The family of an alcoholic asks the nurse where they can go for support in their community. Which of the following would be an appropriate support group for the nurse to recommend?

Al-Anon4

In response to information that a 5-year-old's death is imminent, the parents express intense anger at the staff, and they are critical of the care their son is receiving. What is the best therapeutic intervention on the parents' behalf?

Allow the parents to express their emotions about their son dying. Submit

What is a priority nursing problem in the care plan for a manic client with bipolar disorder?

Altered nutrition2

When caring for a client admitted for medically monitored detoxification from alcohol, the nurse would assess for which of the following signs and symptoms of withdrawal?

Anorexia, irritability, nausea, and tremors2

Which nursing intervention has highest priority for a client with bulimia nervosa?

Assist the client to identify triggers to binge eating.2

A nurse is caring for a client with cardiac disease who is beginning to experience denial. What is a primary indicator of denial?

Attempts to minimize the illness3

A client with a diagnosis of manic-depressive disorder has been receiving lithium carbonate. His serum level is 0.3 mEq/l. What is the interpretation of this level?

Below the desired range2

The nurse is preparing a teaching plan for a client who is going to be discharged with a prescription for lithium. What will the nurse teach the client to watch for regarding the signs and symptoms of lithium toxicity?

Confusion, ataxia, gastrointestinal upset3

Which of the following defects is most commonly associated with Down syndrome?

Congenital heart disease3

A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment?

Dangerous3

Which assessment findings suggest the client may be hallucinating?

Darting eyes, tilted head, mumbling comments2

What would be important for the nurse to assess for in caring for a client who is schizophrenic?

Delusions and hallucinations2

While performing an admission interview with a client on the substance abuse unit, the nurse is repeatedly told by the client that he is not a drug abuser, although his drug screen was positive for a variety of controlled substances. The nurse understands the client is using which defense mechanism?

Denial4

An older adult client's wife says that he has become increasingly confused, unaware of the presence of others, and combative, and that he does not remember things she has just told him. What is the assessment priority for this client?

Determine if his judgment is impaired.2

An older client has been experiencing confusion. The nurse is trying to determine whether the confusion is related to depression or dementia. In evaluating the client, what specific nursing assessment finding(s) would be helpful in making this distinction?

Determining whether confusion worsens in the evening2

The nurse is caring for a client who the nurse suspects is paranoid. What is an appropriate approach when communicating with this client?

Direct questioning3

The nurse is talking with the family of a dying client. What information should be given to those family members who are present in the client's room?

Family should talk softly to the client whenever they are close to him. Submit

Which of the following would be noted as an adverse effect in a client receiving lithium carbonate?

Fine hand tremors2

A client comes to the nurses' station and is upset and verbally abusive when told that her privileges for walking on the grounds have been revoked. What would be the most effective approach by the nurse?

Firmly but calmly escort the client back to her room. Submit

A nurse in a psychiatric unit observes a client kicking the furniture and walls while yelling that no one visits her. What would be the priority nursing intervention?

Firmly tell the client in a calm and clear tone of voice to stop kicking the furniture. Submit

Which nursing observation would alert the nurse to a possibility of child abuse?

Fractured femur on a 6-month-old4

A diabetic client is admitted for an above-the-knee amputation secondary to peripheral vascular disease. Which emotional response would the nurse expect to observe in the preoperative period?

Grieving over the anticipated loss of her leg3

A nurse is working with children who have been sexually abused by a family member. What overwhelming feelings do these children usually express? (Select all that apply.)

Guilt Angerf Self-blame

Which dinner menu is best suited for a client with acute mania?

Hamburger on a bun, an ear of corn, and an apple4

The nurse is conducting an intake interview with a young man diagnosed with generalized anxiety disorder. What type of behavior would the nurse expect to observe?

Is unable to concentrate and is irritable when questioned4

A young mother has a hospitalized child. She works at night and says if she misses any more work she will be fired. She is worried about leaving her child in the hospital at night because he is so young. What is the basis of the nurse's reply?

It would be better if the mother could stay; however, there is adequate staff to care for the child.4

The nurse is caring for a client who is diagnosed with delirium. What is a priority nursing measure to provide for the client?

Maintaining a safe environment4

What symptoms would indicate to the nurse that the client is probably hallucinating?

Movement of the head, as if trying to hear better, and mumbling3

When the nurse notices the client is unable to maintain eye contact and their chin lowers to the chest, while they look at the floor. Which aspect of communication has the nurse assessed?

Nonverbal communication2

The nurse is caring for a client who is confused. What would be a priority of care for this client?

Offering client frequent meals that are easy to eat3

A client is being monitored for schizophrenia. The nurse would assess the client for the presence of what symptoms?

Paranoia, delusions, hallucinations, and diminished self-care4

Which of the following nursing interventions should be implemented for a client experiencing a manic episode?

Place the client in a quiet area, separate from others.2

The nurse is caring for an alcoholic client who is beginning to experience delirium tremors. What is important to include in the care of this client?

Plan to administer a CNS depressant and reduce environmental stimuli.2

A nurse suspects older adult neglect. What assessment findings would confirm this?

Poor nutrition and hygiene4

The family of a client with Alzheimer's disease asks the nurse about caring for the client. What advice would the nurse give to the family?

Prioritize client care, as well as family and client needs.4

A client with late-stage Alzheimer's disease has a nursing diagnosis of disturbed thought processes. What would be an appropriate nursing intervention for this problem?

Promote a consistent, regular daily routine.4

A client has been on haloperidol, and the progress notes in the client's chart indicate he is beginning to experience tardive dyskinesia. What observations will the nurse make that are characteristic of tardive dyskinesia?

Protrusion of the tongue, puffing of cheeks, and chewing or puckering of the mouth4

What type of setting should the nurse arrange for a client with delirium and altered perceptions of the environment?

Provide a quiet, well-lit room without glare or shadows.2

The nurse is admitting a trauma client to the emergency department. The injuries are not life threatening. What is important for the nurse to consider when interviewing or orienting this client?

Repeat information several times.2

Which technique will best communicate to a client that the nurse is interested in listening?

Restating a feeling or thought the client has expressed2

Familiar environment and routine for an older adult client fulfills which of Maslow's hierarchy of needs?

Safety and security Submit

What is the initial nursing care for the depressed client?

Schedule one nurse to consistently interact with the client and focus on establishing rapport.4

Which of the following would be the appropriate action for the nurse in caring for a client with dementia who has an order for cloth restraints?

Secure the cloth restraint ties to the bed frame to protect the client from injury.2

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client?

Sedation and muscle stiffness2

A client diagnosed with depression is receiving imipramine 200 mg at bedtime. Which assessment finding would indicate a potentially hazardous side effect of this drug?

Seizures

The family is present as their mother is dying. The family needs assistance as the mother's death becomes imminent. How can the nurse best assist the family to begin preparatory grieving?

Supporting them while they share feelings about their mother's impending death4

A parent brings a young child to the clinic, stating that the child fell off the porch swing. Which nursing assessment finding would cause the nurse to closely evaluate the situation for the possibility of child abuse?

The child has red, blue, and green bruised areas on her anterior and posterior trunk.2

The nurse is assessing the dietary history of a 16-year-old female client. Which client symptoms would indicate anorexia nervosa rather than bulimia?

The family states she refuses to stop her extreme dieting Submit

The practical nurse is caring for an infant suspected of being abused. The nurse overhears the mother talking to the infant, "I'm so sorry, baby; I thought I would be so happy once you were born." What is the nurse's interpretation of the mother's behavior?

This represents part of the mother's need for mothering.4

Which finding for a client with an eating disorder most clearly indicates the need for hospitalization?

Urine output less than 30 ml/hr3

The nurse is caring for a client who has an eating disorder. Which nursing interventions would be appropriate for this client?

Weigh the client once a week and contract for the amount of food to be eaten. Submit

The nurse is admitting an older adult client to the long-term care facility. What is the most effective question to assist the nurse to determine the client's level of confusion?

What is your name?4

The nurse on a long-term care unit is planning assignments for the day. What will be important for the nurse to consider in assigning staff to care for a client who is dying?

Whenever possible, assign the same staff to care for the client.4

A client is observed by the nurse opening and closing his fist and mumbling angrily while walking back and forth in his room. The nurse should

attempt to determine the source of anxiety.2

A client who recently emigrated from Asia is admitted to the hospital. The client speaks no English. In order to complete the assessment, communicate appropriately, and determine the client's needs, the nurse should

contact the appropriate hospital department and arrange for a translator to be present.4

A client has been receiving fluphenazine for the past 3 weeks. The nurse's assessment notes the following: oral temperature elevated to 105 degrees F, marked muscle rigidity, agitation, and confusion. The nurse recognizes these findings as often associated with

neuroleptic malignant syndrome.4

A multidisciplinary approach is used for investigation of a family situation. Once the diagnosis of child abuse is established, a nursing care priority is

protecting the total well-being of the child. Submit