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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?

Encourage frequent rest periods throughout the day

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?

Talk with the client about activities they enjoyed with their partner

A nurse is providing teaching to a client who has a new prescription for phenelzine. The nurse should teach the client that which of the following over-the-counter medications can cause a hypertensive crisis when taking concurrently with phenelzine?

Pseudoephedrine

A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment which of the following actions the nurse plan to take next?

Request a mental health consultation for the client. A. Conduct a pregnancy test C. Provide a trained advocate to stay with the client D. Offer prophylactic medication to prevent STIs

A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited the day before. Which of the following cognitive impairments is the client demonstrating?

Confabulation

A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorder?

Dependent B. Paranoid C. Borderline D. Histrionic

A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depresion and a blood pressure of 210/105 mm Hg and a temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first?

Determine the clients prescribed medication regimen

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

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?

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

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. The nurse should instruct the client that which of the following blood tests should be performed periodically?

Glucose

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors?

Plan the client's schedule to allow time to perform rituals

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?

Set realistic limits on the clients behavior

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benzotropine 2 mg IM

Shuffling gait

A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicated an understanding of the teaching? a. "Survivors of abuse often feel guilty." b. "Abusers often have high self-esteem." c. "The honeymoon stage of violence usually gets longer over time." d. "As abuse continues, victims become more determined to be independent."

a. "Survivors of abuse often feel guilty."

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk or complicated grief?

"I feel so empty without my wife that it's hard to get p every morning."

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.)

- Feelings of hopelessness - Anhedonia - Flat facial expression

A nurse is reviewing routine laboratory values for several clients who re taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?

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 is the nurse required to report?

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

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?

Arrange one-to-one observation of the client

A nurse on 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?

Ask the client what the voices are saying

A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?

Attending a relapse prevention group several times each week

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer fist?

Diazepam 5 mg IV bolus

A nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include?

Experiences feelings of isolation

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. he nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension

a nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?

Orthostatic hypotension

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?

Refrains克制，避免 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?

Renew the prescription for the client every 4 hours.

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors should the nurse identify as increasing the client's risk for depression?

The client is female

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take? a. Withhold the next dose of lithium. b. Repeat the lithium level test. c. Administer the next dose of lithium.

c. Administer the next dose of lithium.

A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication? a. Anhedonia b. Waxy flexibility c. Contractions of the jaw d. Incongruent affect

c. Contractions of the jaw

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as me, see, bee, tree. The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia?

clang association

A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract? a. Use projection during group therapy b. Increase self-esteem c. Use bargaining skills for behavioral consequences d. Decrease the number of verbal outbursts

d. Decrease the number of verbal outbursts

A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan? a. Administer olanzapine b. Institute consequences for deliberate behaviors c. Provide a stimulating environment d. Encourage thought stopping techniques

d. Encourage thought stopping techniques

A nurse is reviewing the laboratory results of an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect? a. Blood glucose 100 mg/dL b. T411 mcg/dL c. Potassium 3.7 mEq/L d. Hgb 10 g/dl

d. Hgb 10 g/dl

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?

establish screening programs to identify at-risk clients

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?

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

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

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

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance

A nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head and says, "Please forgive me, I'm not sure what came over me! I don't know why I said those things." The nurse interprets this behavior as which of the following? a. Emotional lability b. Confabulation c. Flight of ideas d. Neologism

a. Emotional lability

A nurse is assessing a client who requests bupropion for smoking cessation. Which of the following findings in the client's history should the nurse recognize as a contradiction for taking this medication? a. Seizures b. Anemia c. Migraines d. Asthma

a. Seizures

A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship? a. Summarize goals and objectives b. Address confidentiality. c. Promote problem solving skills.

c. Promote problem solving skills.

A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection? a. "I would like to sit with you for a while." b. "You feel upset when this happens?" c. "Let's work together to try to solve your problem." d. "Can you tell me what is happening now?

b. "You feel upset when this happens?"

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

A client who is taking lamotrigine and has developed a rash

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?

Aggression toward animals

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?

Avoid looking directly at the light during treatment. Wear sunglasses when outdoors.

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?

Provide frequent high-calorie snacks

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

Administer the medication to the client via IM injection. A. Inform the client that he does not have the right to refuse medication. C. Offer the client the medication at the client schedule dose time D. Implement consciences until the client takes the medication.

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?

Frequently misplaces objects

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?

Inappropriate dress

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately?

Urinary retention

A nurse in a mental health facility is caring for a client who has generalized anxiety disorder. Which of the following statements should the nurse make?

We'll assist you with making decisions

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Contact the facility social worker to obtain the consent. b. Explain implied consent to the client's family. c. Request that the client's guardian sign the consent

c. Request that the client's guardian sign the consent

A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy(ECT) but will not sign the consent form. Which of the following actions should the nurse take?

A. Request that the client's partner signs the consent B. Cancel the scheduled ECT procedure. C. Proceed with preparation for ECT based on implied consent D. Inform the client about the risks of refusing ECT.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

Interview the client in a private setting

A nurse in a mental health facility is making plans for a client's discharge. Which of the following indisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Social worker d. Occupational therapist

c. Social worker

A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider? a. Nausea b. Random blood glucose 130 mg/dL c. Heart rate 104/min d. Sore throat

d. Sore throat

A nurse is providing teaching to a client who has a new prescription for diazepam. Which of the following instructions should the nurse include in the teaching?

This medication can be habit-forming

A nurse is caring for a school aged -child who has conduct disorder and is being physically aggressive to other children on the unit. Which of the following actions should the nurse take first?

Use a therapeutic hold technique. A. Place the child in seclusion C. Apply wrist restrains. D. Administer risperidone

A nurse is providing teaching to a client who has OCD and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy?

Demonstrating performance of hand hygiene at scheduled times

A nurse is caring for a client who has a new diagnoses of bulimia nervosa. Which of the following diagnostic procedures should the nurse anticipate the provider to prescribe during the medical evaluation?

ECG A. Chest x-ray C. Coagulation Studies D. Liver function

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment?

Physical needs

A nurse is caring for a client who has PTSD. Which of the following actions by the client indicates the current treatment plan is effective?

The client reports techniques she uses to promote sleep

A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make?

This medication is an antipsychotic that controls manifestations of schizophrenia

A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse's priority? a. High fever b. Insomnia c. Urinary hesitancy d. Headache

a

A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive- behavioral family therapy in response to which of the following client statements? a. "I want to learn how to change the way I react to problems with my family." b. "I want to understand why my past experiences are affecting my family relationships." c. "I want to improve my family's understanding of each other's boundaries." d. "I want each of my family members to be more aware of each other's feelings."

a. "I want to learn how to change the way I react to problems with my family."

A nurse is providing behavioral therapy for a client who has obsessive- compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought-stopping technique? a. "Keep a journal of how often you check the locks at night." b. "Snap a rubber band on your wrist when you think about checking the locks." c. "Ask a family member to check the locks for you at night." d. "Focus on abdominal breathing whenever you go to check the locks."

b. "Snap a rubber band on your wrist when you think about

A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency? a. A client who reports that she took $20 from the cash register where she works b. A client who reports that her partner ties their child to bed as punishment c. A client who reports that he enjoys smoking marijuana on the weekends d. A client who reports lying to his provider about having suicidal ideation

b. A client who reports that her partner ties their child to bed as punishment

A nurse is providing teaching for the family of a client who has dementia. Which of the following should the nurse include in the teaching as a contributing factor for this disorder? a. Hypotension b. Alcohol use disorder c. Dehydration d. Change in environment

b. Alcohol use disorder

A nurse is assessing a client who has a histrionic personality disorder. Which of the following findings should the nurse expect? a. Lack of remorse b. Attention-seeking c. Splitting of staff d. Identity disturbance

b. Attention-seeking

A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse take during the orientation phase? a. Manage conflict within the group b. Establish a rapport with group members c. Encourage the use of problem solving skills d. Maintain the group's focus on identified issues

b. Establish a rapport with group members

A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication? a. The client reports improved short-term memory. b. The client has decreased euphoric mood. c. The client reports absence of auditory hallucinations. d. The client has decreased anxiety

b. The client has decreased euphoric mood.

A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms? a. Suppression b. Reaction formation c. Identification d. Compensation

c

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'?

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

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?

"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?

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

A nurse is planning care 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?

"It is easier to talk about my feelings now."

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?

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

A nurse is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client's depression. Which of the following statements by the nurse is appropriate?

"It's important that the client feels safe verbalizing how she is feeling." a. "Please don't take what the client said seriously when she is depressed." c. "Everybody feels that way about the client, so don't worry about it. d. "I'll change your assignment to someone who doesn't have depressive disorder.

a nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks thenurse about this medication. Which of the following responses should the nurse make?

"Succinylcholine is given to reduce muscle movement during therapy."

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?

"You might experience difficulties with sexual functioning while taking this medication."

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse administer?

14

A nurse is assessing a client who has been taking thioridazine hydrochloride for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take?`

Administer benztropine

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates that the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take?

Administer the medication

A nurse is caring for a client who has been unable to leave the house for the past 10 ears without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse should identify that the client is exhibiting which of the following disorders?

Agoraphobia

A nurse is assessing a client who has a psychotic disorder and a new prescription for haloperidol. The client is pacing the hallway and states "I can't seem to sit still.: Which of the following extrapyramidal side effects is the client likely experiencing?

Akathisia

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 client's turn they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer

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?

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?

Ask the family member is 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?

Attention to body language

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?

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

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client?

Chicken nuggets, crackers with cheese sticks, and a cookie FINGER FOODS

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, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

Clang association

A nurse in a provider's office is collecting a health history from 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?

Dark urine

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he became angry and tells her to live. Which of the defense mechanisms is the client demonstrating?

Displacement A. Rationalization B. Denial C. Compensation

A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client?

Dizziness

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 attempt to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

Do not administer the lorazepam

A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

Headache

A nurse in the emergency department is assessing a client who has cocaine intoxication. Which of the following should the nurse expect?

Hypervigilance (paranoia)

A nurse in a mental health clinic is planning car for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

Instruct the client to avoid driving during initial therapy

A nurse is assessing a client who has been taking and antipsychotic medication for 6 years and the provider has started tapering off the dosage. The nurse should monitor the client for which of the following manifestations of tardive dyskinesia

Involuntary tongue protrusion

A nurse is planning care for a client who has schizophrenia and reports auditory hallucination. Which of the following interventions should the nurse include in the plan?

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

A nurse in an alcohol treatment facility is caring for a client who states, "My job is so stressful that the only way I can cope is to drink." The nurse should recognize that the client is displaying which of the following defense mechanisms? a. Repression b. Rationalization c. Introjection d. Intellectualization

Rationalization

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?

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 take?

Report the occurrence to the charge nurse

a nurse is discussing the home care of a client who has advanced Alzheimer's disease with he client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommended to the caregiver?

Respite care

A nurse is caring for a client who has a severe anxiety disorder and is in a state of panic in the day room. Which of the following actions should the nurse take?

Speak to the client in a calm voice

A nurse in a n 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?

St. John's wort

A nurse is assessing a child in the emergency department. Which of the following findings places the child at greatest risk of physical abuse? a. The child is 10 years old b. The child is homeschooled c. The child has no siblings d. The child has cystic fibrosis

The child who is homeschooled

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?

The client is interested in what the nurse is saying

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash

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?

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 that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations

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?

The client will refrain from self-mutilation

A nurse is providing teaching to the daughter of an older adult client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching? a. "I will limit my mother's clothing choices when she is getting dressed." b. "I will provide my mother with detailed instructions about how to perform self-care." c. "I will wake my mother up a couple of times in the night to check on her." d. "I will discourage my mother from talking about her physical complaints."

a. "I will limit my mother's clothing choices when she is getting dressed."

A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching? a. "This medication is given to help with extrapyramidal side effects." b. "This medication is given to help with your depression." c. "Benztropine helps alleviate your hallucinations." d. "Benztropine is used to counteract your tachycardia."

a. "This medication is given to help with extrapyramidal side effects."

A nurse is counseling an adult client whose parent just died. The client states, "My son is 4, and I don't know how he'll react when he finds out that his grandpa died." The nurse should inform the client that the preschool-age child commonly has which of the following conceptions of death? a. Death is not permanent and the loved one may come back to life. b. Death is contagious and can cause other people he loves to die. c. Death creates an interest in the physical aspects of dying. d. Death is a part of life that eventually happens to everyone.

a. Death is not permanent and the loved one may come back to life.

A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take? a. Encourage the client to suppress feelings of trauma. b. Assign the same staff to care for the client each day. c. Address the client in an authoritative manner. d. Limit the amount of time spent with the client.

a. Encourage the client to suppress feelings of trauma.

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. Position the mattress on the floor b. Install sensor devices on outside doors c. Encourage physical activity prior to bed time. d. Put locks at top of doors e. Place the client in a reclining chair.

a. Position the mattress on the floor d. Put locks at top of doors

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider? a. Recent head injury b. Hepatitis B infection c. Hypothyroidism d. Knee arthroplasty 1 month ago

a. Recent head injury

A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan? a. Reinforce the client's orientation with a calendar. b. Refute the client's perception of visual hallucinations. c. Teach the client assertive techniques. d. Assign the client to a different caregiver each shift.

a. Reinforce the client's orientation with a calendar.

A nurse is assessing the boundaries of a client's family. One of the family members says to the client, "I know exactly what you're thinking right now." The nurse should recognize that the family member is displaying which of the following types of boundaries? a. Rigid b. Inconsistent c. Enmeshed d. Clear

a. Rigid- wrong d

A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. Self-mutilation b. Pacing back and forth c. Preoccupation with details d. Disorganized speech

a. Self-mutilation

A nurse is caring for a client who has schizophrenia and started taking clozapine 2 months ago. Which of the following laboratory results should the nurse report to the provider? a. WBC 3000/mm cubed b. Potassium 4.2 mEq/L c. Hgb 16 g/dL d. Platelets 300,000/mm cubed

a. WBC 3000/mm cubed

A nurse is reviewing medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior? a. Schizoid personality disorder b. Alcohol intoxication c. Dysthymic disorder d. Long-term isolation

b. Alcohol intoxication

A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To which of the following members of the client's interprofessional team should the nurse refer the client in order to help him relearn how to use eating utensils? a. Neuropsychiatrist b. Occupational therapist c. Physical therapist d. Social worker

b. Occupational therapist

A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm cubed c. Urine pH 5.6 d. RBC 4.7/mm cubed

b. Platelets 90,000/mm cubed

A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse's priority at this time? a. Contact the adolescent's parents b. Suggest the adolescent join a support group c. Ask the adolescent if he is considering hurting himself

c. Ask the adolescent if he is considering hurting himself

A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Place the client in a group therapy session b. Rotate staff members who work with the client c. Encourage the client to participate in physical activities d. Distract the client with increased environmental stimuli

c. Encourage the client to participate in physical activities

A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Encourage the client to display anger toward the cause of crisis b. Tell the client that his life will soon return to normal c. Identify the client's usual coping style d. Help the client focus on a wide variety of topics regarding the crisis

c. Identify the client's usual coping style

A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take? a. Ask the client if she has eaten foods containing tyramine. b. Give regular insulin subcutaneously to the client. c. Prepare the client for electroconvulsive therapy d. Administer dantrolene IV bolus to the client

c. Prepare the client for electroconvulsive therapy

A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication? a. Blocks aldehyde dehydrogenase b. Prevents the anxiety of abstinence c. Reduces substance craving d. Decreases the likelihood of seizures

c. Reduces substance craving

A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam? a. Bradycardia b. Stupor c. Afebrile d. Hypertension

d. Hypertension

A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Slurred speech b. Hypotension c. Bradycardia d. Hyperthermia

d. Hyperthermia

A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take? a. Seat the client at a dining table with six of more residents b. Provide the client with several choices for meal selection c. Give complete directions before starting client care d. Use symbols to assist the client in locating rooms

d. Use symbols to assist the client in locating rooms

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?

monitor the client's cardiac rhythm during the procedure

A nurse is taking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

suggest forming a weekly support group for parents who have experienced the death of a child

A nurse is providing discharge teaching for a client who has a new prescription for doxepin. Which of the following adverse effects should the nurse inform the client is associated with this medication?

Drowsiness

A nurse is assessing a client who has schizophrenia. The client states I need to get my gummamoshu from my house. The nurse recognizes this statement as an example of which of the following?

Neologism making up of words

A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity? a. Calcium 9.0 mg/dL b. Sodium 130 mEq/L c. Chloride 98 mEq/L d. Potassium 5.0 mEq/L

b. Sodium 130 mEq/L

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression? a. "I don't know how I could cope if I didn't have my family's support." b. "It'll be a long time before I'm happy again." c. "I don't feel anything but numbness anymore." d. "I feel like I'm angry at the whole world right now."

c. "I don't feel anything but numbness anymore."

A nurse is providing teaching for a school-age child and his parent regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will provide a low-sodium diet for my son." b. "I will make sure my son takes the last dose of the day by 4 p.m." c. "I should expect my son to develop hand tremors." d. "I should contact my doctor if my son urinates excessively."

c. "I should expect my son to develop hand tremors."

A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the following information should the nurse include? a. "This therapy works as a cure for major depressive disorders." b. "You will be awake and alert during the procedure." c. "You might experience confusion for a few hours after treatment." d. "This therapy will stimulate the vagus nerve to improve your mood."

c. "You might experience confusion for a few hours after treatment."

A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority? a. The client joins a support group. b. The client identifies techniques to reduce her stress. c. The client develops a safety plan. d. The client identifies support systems.

c. The client develops a safety plan.

A nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the following findings indicated that the client is at an increased risk for suicide? a. Increased energy b. Hypersomnia c. Unkempt appearance d. Psychomotor retardation

c. Unkempt appearance

A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide? a. The client is married b. The client is female c. The client is 50 years of age d. The client has diabetes mellitus

d c-???

A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills? a. "How does this situation affect your life?" b. "Do you see your current situation affecting your future?" c. "Can you describe how you are currently feeling?" d. "How have you dealt with similar situations in the past?"

d. "How have you dealt with similar situations in the past?"

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routing activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make? a. "Older adults are usually diagnosed with depressive disorder as they age." b. "Everyone gets depressed from time to time." c. "You shouldn't worry about this, because depressive order is easily treated." d. "Tell me the reasons why you think your mother is depressed."

d. "Tell me the reasons why you think your mother is depressed."

A nurse is teaching the parent of a school-age child who has ADHD and a prescription for atomexine 40 mg daily. Which of the following information should the nurse include in the teaching? a. Expect the child to gain weight while taking this medication. b. Crush the medication and mix it with 120 mL (4 oz) of juice. c. Therapeutic effects will occur within 24 hours of starting treatment d. Administer the medication before the child goes to school in the morning.

d. Administer the medication before the child goes to school in the morning.

A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect? a. Readily initiates conversation b. Enjoys imaginative play c. Strong relationship with siblings and peers d. Attachment to objects that spin

d. Attachment to objects that spin

A nurse is performing a mental status examination for a client who has schizophrenia. The nurse should recognize that which of the following actions requires the client to think abstractly? a. Explain what to do if he misses the bus. b. Determine the meaning of a proverb c. Name the last three presidents of the US d. Count by adding sevens consecutively.

d. Count by adding sevens consecutively. - wrong = cognitive a

A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first? a. Request that the parent leave the room while interviewing the child. b. Report suspected abuse to Child Protection Services. c. Ask the child how the injury occurred. d. Determine the immediate safety needs of the child.

d. Determine the immediate safety needs of the child.

A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Weigh the client twice a day b. Prepare the client for electroconvulsive therapy c. Set a weight gain goal of 2.2 g (5 lb.) per week d. Encourage the client to participate in family therapy

d. Encourage the client to participate in family therapy

A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention? a. Secure the client's valuable possessions b. Limit loud noises in the client's environment c. Encourage the client to participate in structured solitary activities. d. Provide high-calorie snacks to the client.

a. Secure the client's valuable possessions

A nurse is creating a plan of care for a client who has a major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Discourage the client from expressing feelings of anger. b. Identify and schedule alternative group activities for the client. c. Encourage physical activity for the client during the day. d. Keep a bright light on in the client's room at night.

b. Identify and schedule alternative group activities for the client.