Version 3 SCREENSHOT

A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client's chief complaint in the medical record? a.) Client reported that she had sexual relations against her will. b.) Client claims that she was forced to participate in sexualintercourse. c.) Client has been sexually assaulted. d.) Client states, "my date raped me tonight."

d.) Client states, "my date raped me tonight."

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder? A A young woman who suddenly goes blind with no indication of organic pathology. B An older adult who continuously complains of a headache and back pain. C An adolescent who becomes extremely anxious about going outside. D A middle-aged man who is complaining of shortness of breath and is diaphoretic.

A A young woman who suddenly goes blind with no indication of organic pathology.

A female client is brought to the emergency department after police officers found her disoriented, disorgarized, and confu determines that the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority? A Acute confusion. B Self-care deficit. C Ineffective community coping. D Disturbed sensory perception.

A Acute confusion.

A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes of open places and crowds. Which nursing problem applies to the this client's behavior? A Anxiety related to real or perceived threat to physical integrity. B Risk-prone health behavior related to self-esteem assault. C Risk for injury related to inability to communicate. D Ineffective protection to guard self from internal or external threats.

A Anxiety related to real or perceived threat to physical integrity.

A female client who is a retired school teacher, is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of the client's behavior by the nurse is likely to be most accurate? A Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. B Should be encouraged as representative of the client's non-destructive method of fear expression. C Unacceptable, and limits should be set to encourage the client to maintain her independence. D Should be accepted by staff as the first step the client must experience in the grieving process.

A Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety.

A client with depression does not want to communicate with friends, uses television watching as a means the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan? A Focus on small achievable tasks, not taxing problems. B Concentrate on and ventilate emotions when distressed. C Relax and reduce the amount of effort to solve the problem. D Shift attention from self to the needs and requests of others.

A Focus on small achievable tasks, not taxing problems.

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts. "What took you so long to get in here!" Which action should the nurse implement? A Provide for personal space B Stand in the doorway. C Encourage the client to sit down D Request backup from the staff.

A Provide for personal space

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition? A Somatization. B Reexperience. C Preoccupation. D Disorganization.

A Somatization.

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client? A Take the medication each morning beginning 48 hours after your last drink of alcohol. B Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily. C Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication. D Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.

A Take the medication each morning beginning 48 hours after your last drink of alcohol.

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. which intervention is best for the nurse to implement? Ask the client to describe and identify the source of the feelings. Provide education about ways to cope with anxiety. Assist the client with relaxation techniques in the group. Escort the client from the group to reduce stimuli.

Assist the client with relaxation techniques in the group.

An adult male who is admitted to the mental health clinic is alert and oriented to person, place, time, and situation. His affect is blunted, his mood dysphoric, and the nurse identifies his responses as tangential with a paranoid theme when he states, "I have a chip inside my head that is speaking to me." Based on these assessment findings, which nursing problem is best to include in this client's initial plan of care? A Disturbed sensory perception related to grandiose self beliefs. B Disturbed thought process related to paranoid ideation. C Impaired verbal communications related to psychosis. D Impaired social interaction related to unrealistic thought processes:

B Disturbed thought process related to paranoid ideation.

The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The nurse think of other things and finds it difficult to control emotions. Which action should the nurse take first? A Suggest the need for a psychiatric consultation. B Explore changes in life that have occurred after the loss. C Encourage attending a local support group. D Offer a referral to pastoral counseling.

B Explore changes in life that have occurred after the loss.

The nurse is conducting client assessments in an outpatient psychiatric clinic. Which client finding is characteristic of illness anxiety? A logical response to questions asked. B Increased talkativeness and pressure to keep talking. C Ritual daily breast exams for fear of cancer. D Poor concentration and slow thought process.

B Increased talkativeness and pressure to keep talking.

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit? A Compromised family coping. B Ineffective sexual patterns. C Disturbed sensory perception. D Impaired environmental interpretation.

B Ineffective sexual patterns.

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety, minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do? A Help the client know they will not always feel this way. B Reinforce personal strengths observed in the client. C Inquire respectfully about the events of the departure. D Suggest ways to problem solve adapting to the new home.

B Reinforce personal strengths observed in the client.

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A Understands the purpose of the medication regimen. B Sleeps at least six hours a night. C Meets scheduled appointment with the dietitian. Describes the reasons for hospitalization.

B Sleeps at least six hours a night.

A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A Encourage the client to exercise. B Teach the client to develop a plan for daily structured activities. C Provide education on methods to enhance sleep. D Suggest that the client develop a list of pleasurable activities.

B Teach the client to develop a plan for daily structured activities.

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? A "The voices are telling me to kill the next person I see" B "The fire is burning my skin away right now." C "The nurse at night is trying to poison me with pills." D 'The snakes on the wäll are going to eat me."

C "The nurse at night is trying to poison me with pills."

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone, When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take? A Medicate the client with the prescribed antipsychotic thioridazine. B Direct client to occupational therapy to distract him from somatic complaints. C Administer the prescribed anticholinergic benztropine for dystonia. D Offer the client a prescribed physical therapy hot pack for muscle spasms.

C Administer the prescribed anticholinergic benztropine for dystonia.

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first? A Monitor the client after meals for possible vomiting. B Provide a supportive, structured environment for meals. C Assess weight, vital signs, potassium and other electrolytes. D Discuss alternative strategies for binging and purging.

C Assess weight, vital signs, potassium and other electrolytes.

A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care? A Identify the feelings associated with his behavior. B Describe why he is feeling fearful about his finances. C Delay business decisions until his mania subsides. D Seek legal counsel when making business decisions.

C Delay business decisions until his mania subsides.

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related? A Erythema of the localized lesions. B Ecchymotic blood accumulations. C Evidence of patches of lost hair, D Episodic complaints of pruritus.

C Evidence of patches of lost hair,

During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse? A The nurse is reprimanded for divulging confidential patient information without obtaining informed consent. B Both the nurse and therapist are reprimanded for divulging confidential patient information to others. C The nurse and therapist will be asked to educate other team members on appropriate sharing of client information. D The therapist is reprimanded for divulging confidential patient information without obtaining consent.

C The nurse and therapist will be asked to educate other team members on appropriate sharing of client information.

The nurse plans to use role playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapist? A An adult with schizophrenia who often refuses to take prescribed antipsychotic medications. B A hyperactive 4-year-old who has recently been tested for autism. C An older adult resident of a long-term care facility who sometimes takes other residents' belongings. D An adolescent who is depressed over not being accepted by peers.

D An adolescent who is depressed over not being accepted by peers.

A client is experiencing high levels of stress caused by social situations that involve performance and judgment. The short-term medication. Which class of medications should the nurse expect to administer to the client? A Antipsychotics. B Norepinephrine reuptake inhibitors. C Selective serotonin reuptake inhibitors. D Benzodiazepines.

D Benzodiazepines.?

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications includes inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the client? A Temperature. B Urinary output. C Respiratory rate. D Blood pressure.

D Blood pressure.

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit? A 24-hour urinary output. B Blood sugar level. C White blood cell count. D Current vital signs.

D Current vital signs.

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information? A Any history of heart disease. B Current weight. C Familial history of mental illness. D Medication history.

D Medication history.

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool? A Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake. Consumption, liver enzyme, gastrointestinal complaints and bleeding. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener." Cancer screening results, anger, gastritis, daily alcohol intake.

Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener."

The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? Determine if the mother has other children who do not have developmental disabilities. Ask the mother if she has ever thought about harming herself or her child. Encourage the mother to write thoughts and feelings in a journal. Reassure the mother that her child will achieve some growth and development milestones.

Encourage the mother to write thoughts and feelings in a journal.

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client? The other nurses and I are here to help you get better. I do care about you as a person but nothing more. You don't think the other nurses care about you? I am not the best nurse. All the nurses are good.

The other nurses and I are here to help you get better.