Care Management 2 ATI Questions

A nurse is assessing a client who was diagnosed with schizophrenia. Which of the following client findings is considered a positive symptom of schizophrenia? A. Hallucinations B. Social withdrawal C. Anergia D. Flat affect

A. Hallucinations

A nurse is reviewing the medication history of a client who has mild intermittent asthma. The nurse should anticipate a RX for which of the following inhalers for the client? A. Ipratropium B. Albuterol Sulfate C. Tiotropium D. Budesonide

B. Albuterol Sulfate

A nurse is caring for a client who has schizophrenia and states, " My doctor is trying to kill me. Which of the following responses should the nurse make? A. Why would you say that your doctor is trying to kill you? B. It must be frightening to feel that your doctor is trying to kill you C. Your doctor wants to help you not kill you D. How long has your doctor been trying to kill you

B. It must be frightening to feel that your doctor is trying to kill you

A nurse is caring for a client who has generalized anxiety disorder. Which of the following goals should the nurse include in the discharge plan of care for this client. A. Use whistling or singing as a distraction to control hallucinations B. Make independent decisions about daily events C. Verbalize a realistic perception of personal appearance D. Decrease the use of ritualistic behaviors

B. Make independent decisions about daily events GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. Encourage deep breaths B. Mobilize secretions in the airways C. Dilate the bronchioles D. Stimulate the cough reflex

B. Mobilize secretions in the airways

A nurse is administering medications to a client who is recovering from a stroke and has right sided paralysis. The nurse places the clients medication on the left side of the mouth and administers pills one at a time. Which of the following ethical princiiples is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. JUstice

B. Nonmaleficence - duty to do no harm and to protect cleints from harm by eliminating threats. - the actions by the nurse are important for the safety of the client by preventing aspiration

A nurse is caring for a client who has a stroke and requires assistance performing ADLS. THe nurse should collaborate with which of the following members of the interprofessional care team? A. Speech B. OT C. Social worker D. Dietitian

B. OT

A nurse is caring for a child with CF who has a pulmonary infection. Which of the following findings is the nurses' priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

D. Inability to clear secretions - REMEBER ABCs BITCH

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation labs B. Apply pneumatic compression boots C. Request referral for speech D. Keep the client NPO

D. Keep the client NPO - stroke patients are at risk for aspiration ABCS!!!!

A nurse in an ED is assessing a school aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. sudden decrease in wheezing

D. sudden decrease in wheezing - silent chest indicates ventilatory failure and imminent resp. arrest

A nurse is assessing a school aged child after a ventriculoperitoneal shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

A. Abdominal distention - a VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurses priority? A. Ask the client what the voices are saying B. Focus the client's attention on reality based activities C. Make eye contact when speaking with the client D. Encourage the client to listen to music through headphones

A. Ask the client what the voices are saying The greatest risk for this client is an injury to self or others due to command hallucinations

A nurse is providing teaching to the parent of a child who has CF and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra abdominal pressure

A. Bulky stools - implement interventions to help decrease the bulk of the childs stools

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, and tree. The nurse should recognize that the client is demonstrating which of the following positive manifestations of schizophrenia? A. Clang association B. Echolalia C. Magical thinking D. Word salad

A. Clang association

A nurse is assessing a client who has schizophrenia. The client suddenly states, I am blue, so are you, and I am leaving on a choo choo choo A. Clang association B. Word salad C. Neologism D. Echolalia

A. Clang association a pattern of speech that rhyme or contain a string of words that have the same beginning sounds

A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the past 2 months. Which of the following findings demonstrates that the medication has been effective? A. Client reports that hallucinations occur less frequently B. Client sleeps uninterrupted for 6 hr each nigh C. Client reports that she is the "most important person the unit" D. The client demonstrates stereotyped behaviors

A. Client reports that hallucinations occur less frequently

While participating in a community health fair, a nurse is providing information to a client who has a BP of 150/90 during screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go the nearest ED C. Instruct the client to follow-up with a provider within 6 mnths D. Explain to the client that he is not at risk unless he has manifestations of HTN

A. Give the client a written record of his BP to bring to his provider

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened Immune Response D. Bleeding tendencies

A. Hyperglycemia - stress causes an increased secretion of cortisol, which can lead to HTN and Hyperglycemia

A nurse is providing teaching to a parent of a child who has asthma and a new RX for a cromolyn sodium MDI. Which of the following statements by the parent indicates the need for further teaching? A. I will give my child a dose as soon as wheezing starts B. My child should rinse out his mouth after using the inhaler C. My child should exhale completely before placing the inhaler in his mouth D. If my child has difficulty breathing in the dose, a spacer can be used

A. I will give my child a dose as soon as wheezing starts

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the childs protein intake B. Decrease the childs calorie intake C. Increase the childs fiber intake D. Decrease the childs salt intake

A. Increase the child's protein intake

A nurse is caring for an older client who had a stroke. After assessing the ABCs , which of the following assessments is the nurse's priority? A. LOC B. Muscle tone C. Sensory CHanges D. Gag Reflex

A. LOC

A nurse in a mental health facility is admitting a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self mutilation C. Delusional behavior D. Splitting

A. Lack of remorse clients who have antisocial personality disorder lack empathy for others and show no remorse or guilt for callous behavior

A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has authorized the client's family to bring food from home. Which of the following foods should the nurse recommend that the client avoid? A. Lentil soup B. Cheese sandwich C. Yogurt D. Raisins

A. Lentil soup - gout, renal calculi, or both in conjunction need to have diets rich in purines

A client has a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse recommend to the client. (SELECT ALL) A. Nurse B. OT C. Speech therapies D. PT E. Respiratory therapies

A. Nurse B. OT C. Speech therapies D. PT

A nurse is planning care for a client who had a stroke. THe client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hours B. Limit the clients daily fluid intake C. Request an indwelling catheter D. Ambulate the client to the bathroom every 30 mins

A. Offer the client a bedpan every 2 hours

A nurse is creating a plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include? A. Offering high calorie beverages to a client who is in the manic phase of bipolar B. Practicing relaxation techniques with a client who has an anxiety disorder C. Assisting a client who has a depressive disorder with decision making regarding group activities D. Providing teaching to a client who has schizophrenia about a new prescription for clozapine

A. Offering high calorie beverages to a client who is in the manic phase of bipolar Address the clients physiological need for food and water first aka Basic needs

A nurse is caring for a client who has schizophrenia and a prescription for chlorpromazine. For which of the following adverse effects should the nurse monitor? A. Orthostatic hypotension B. Diarrhea C. Urinary Frequency D. Bradycardia

A. Orthostatic hypotension

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 mins the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborns glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for penylketouria

A. Perform a heel stick to check the newborns glucose level

A nurse is assessing a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

A. Positive Positive symptoms are seen early in clients who have schizophrenia and are easier to detect than other types of symptoms.

A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Present a single idea in a sentence B. Avoid using nonverbal communication techniques C. Speak loudly D. Use simplified language

A. Present a single idea in a sentence - loss of ability to understand or express speech,

A nurse is providing dietary teaching to the parent of a toddler with CF. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

A. Provide a high fat diet for the toddler - children with CF have impaired intestinal absorption of fat

A nurse is reviewing the medical record of a client. The medication administration record shows the client is taking clopidogrel. Which of the following events should the nurse expect in the client's medical history? A. Recent myocardial infraction B. HX of hemorrhagic stroke C. Current outbreak of psoriasis D. HX of HTN

A. Recent myocardial infraction - the nurse should expect to indicate a hx of an atherosclerotic event such as a MI, ischemic stroke, or peripheral vascular disease - clopidogrel is a antiplatelet drug

A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? A. Relieve the clients pain B. Encourage the client to increase fluid intake C. monitor the clients I&O D. Strain the clients urine

A. Relieve the clients pain

A nurse is caring for a client who has schizophrenia. The client states, my internal organs have turned to stone. The nurse should document this finding as which of the following types of delusions? A. Somatic B. Reference C. Persecutory D. Grandiose

A. Somatic believe that a body part is no longer functioning in a realistic or expected manner

A nurse is planning care for a female client who has severe IBS and RX for alosetron. Which of the following interventions should the nurse include in the plan of care? A. The client must sign an agreement with the provider before beginning alosetron B. The client must stop taking medication if diarrhea continues for 1 week after beginning C. The client should expect to have a slower heart rate while taking alosetron D. The client should use a barrier birth control method because alosetron interacts with oral contraceptives

A. The client must sign an agreement with the provider before beginning alosetron - medication has a fatal adverse effects associated with constipation and bowel obstruction

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

A. The clients ability to clear oral secretions - ABCS ALWAYS!!!!!

A nurse is assesing a client who reports using several herbal and vitamin supplements daily. The nurse should recognize that saw palmetto is a supplement used by clients to elicit which of the following therapeutic effects? A. Urinary health promotion B. Immune system stimulation C. Decreased leg pain from arterial disease D. Prevention of nausea caused by motion sickness

A. Urinary health promotion

A nurse is assessing a client who has a new prescription for chlorpromazine to treat schizophrenia. The client has a mask like facial expression and is experiencing involuntary movements and tremor. Which of the following medications should the nurse anticipate administering? A. amantadine B. bupropion C. phenelzine D. hydroxyzine

A. amantadine Patient is experiencing Parkinsonism, which is an adverse effect of the antipsychotic medication chlorpromazine

A nurse is assessing a client who has CF. Which of the following pieces of information indicates a therapeutic response to pancreatic enzyme replacement? A. is having 1 - 2 bowel movements daily B. glucose level is elevated C. experienced weight loss D. abdominal distention

A. is having 1 - 2 bowel movements daily - indicates adequate absorption of food and therapeutic response to pancreatic enzyme replacement

A nurse is a member of quality improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? A. paralysis of a clients lower extremities occurred following epidural B. A client fall during ambulation did not result in client injury C. A clients family member complained that a nurse was culturally insensitive D. Surgery to the wrong site was stopped prior to a procedure

A. paralysis of a clients lower extremities occurred following epidural

A nurse is caring for a shcool-aged child who has cystic fibrosis and has been using a corticosteroid inhaler for long-term treatment. Which of the following findings should the nurse identify as an adverse effect of long-term use of this medication? A. small stature for age B. decreased weight C. Poor dentition D. Atrophied muscles

A. small stature for age

A nurse is planning recreational activities for a young adult who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client? A. walking with a staff member B. playing ping-pong in the dayroom with another client C. Playing basketball with other clients in the gym D. Riding a stationary bike alone in the fitness room

A. walking with a staff member

A nurse is teaching a group of newly licensed nurses about violations of client rights. Which of the following examples of a violation of client rights should the nurse include the teaching? A. A client who is confused and recovering from sx has mitten restraints placed to prevent disruption of an abdominal wound. B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at the nurse of the opposite sec C. A health care proxy releases the medical records of a client to a long term care facility for a placement evaluation D. The parents of a 16-year who has gunshot wounds decide to limit their child's visitors to family members only

B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at the nurse of the opposite sex - Seclusion is for patients demonstrating violent or self destructive behavior

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the clients perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infectiosn

B. Addressing the clients perception of the disease process and what might have triggered past attacks

A nurse is caring for a client who has schizophrenia and started taking a 1st gen antipsychotic 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify whether the client is experiencing which of the following adverse effects of antipsychotic medications? A. Neuroleptic malignant syndrome B. Akathisia C. Anticholinergic toxicity D. Opisthotonos

B. Akathisia Akathisia is an extra pyramidal affect that can occur within 2 months of starting 1st gen antipsychotic

A nurse is developing a plan of care for a client after a recent stroke who has a hx of GERD. Which of the following disorders should the nurse plan to monitor this client? A. Duodenal ulcer disease B. Aspiration pneumonia C. Viral pneumonia D. Esophageal varices

B. Aspiration pneumonia

A nurse is providing teaching to a young adult client who has HX of calcium oxalate renal calculi. Which of the following instructions should the nurse include? A. Drink fruit punch or juice at every meal B. Consume 1000 of calcium daily C. Take 1g of vitamin C daily D. Increase your daily bran intake

B. Consume 1000 of calcium daily

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

B. Difficulty with speech

A nurse is conducting dietary teaching with a client who has a history of renal calculi. Which of the following instructions should the nurse include in the teaching? A. Consume foods containing vitamin C B. Drink 3.8L of water throughout the day C. Suggest almonds as a snack D. Limit sodium intake to 3 g per day

B. Drink 3.8L of water throughout the day - helps keep the urine diluted and decrease the risk of kidney stone formation

A nurse is preparing to administer a feeding via a GT to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the clients bed C. Flush the tube with .9 sodium chloride for irrigation D. Verify that the clients gastric pH is above 4

B. Elevate the head of the clients bed - patients with brain injuries are typically unable to swallow effectively and thus cannot protect their airway from aspiration

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 - 2 hr of delivery? A. Nalaxone B. Erythromycin ophthalmic ointment C. Poractant alfa D. Rotavirus immunizations

B. Erythromycin ophthalmic ointment

A nurse is assessing the respiratory status of a newborn who was born 2 hrs ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. RR of 56 D. Irregular RR

B. Expiratory grunting - indication of respiratory distress that is caused by narrowing of the bronchi

A nurse is assessing a client who has schizophrenia. which of the following statements by the client should the nurse recognizes as an erotomaniac delusion? A. My coworker is trying to poison me because he is afraid I will take his job B. I have only met Jenny twice, but I know she loves me C. I am selling my house before the earthquake hits in May D. The foil on my walls prevents the government from controlling me

B. I have only met Jenny twice, but I know she loves me Believes another person desires him or her romantically after meeting only a few time is demonstrating an erotomaniac delusion

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. I will use my peak flow meter whenever I feel SOB B. I will continue to take my medication when my peak flow rate is in the green zone C. I need to use the average of 3 readings when I measure my flow rate D. My asthma is being controlled if my flow rate is in the yellow zone

B. I will continue to take my medication when my peak flow rate is in the green zone

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgement C. Rapid change in personality D. Disturbances in perception

B. Impaired Judgement Impaired judgement occurs in clients who have dementia as they lose their ability to reason, think abstractly, and have rational thoughts.

A nurse is caring for a term newborn 90 mins after a scheduled c section. The newborns APGAR score was 9. The HR is 120, RR 70. There are no indications of nasal flaring, or grunting, retractions. Which of the following actions should the nurse take? A. Request a RX for CPAP B. Initiate close observations of the newborn for indications of RD C. Consult a respiratory therapist for chest physiotherapy D. Request and order for nitric oxide therapy

B. Initiate close observations of the newborn for indications of RD - The newborn has manifestations of transient tachypnea. This condition is thought to be a result of an incomplete clearance of fluid form the lungs at birth

A nurse is providing teaching to a newly licensed nurse about metoclopramide. The nurse should highlight that which of the following conditions is a contraindication to this medication? A. hyperthyroidism B. Intestinal obstruction C. Glaucoma D. Low blood pressure

B. Intestinal obstruction - Metoclopramide reduces N/V by increasing gastric motility and promoting gastric emptying

A nurse is caring for a client who is receiving chlorpromazine to treat schizophrenia. Which of the following statements by the client should prompt the nurse to notify the provider immediately? A. My last bowel movement was 2 days ago B. My tongue keeps moving like a worm C. I feel dizzy when I stand up too quickly D. I can't stop blinking when I'm in the sun

B. My tongue keeps moving like a worm - Involuntary tongue movement indicates that this client is at greatest risk for tardive dyskinesia

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by non-rebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute RDS? A. Temp of 38c B. PaO2 50 C. Rhonchi D. Hypopnea

B. PaO2 50 - client who has manifestations of ARDS has a lower PaO2 level. Hypoxemia after treatment with oxygen is a manifestation of ARDS

A nurse is providing instructions about pursed-lip breathing for a client who has COPD w/ emphysema. This breathing technique accomplishes which of the following? A. Increased oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis -oligohydramnios is a volume of amniotic fluid that is < 300mL during the 3rd trimster

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which fo the following acid - base imbalance? A. Resp. Alkalosis B. Resp. Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

B. Resp. Acidosis - common in COPD because patient is unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs

A nurse is teaching a client who has asthma and a RX for a fluticasone dry power inhaler. Which of the following instructions should the nurse include in the teaching? A. This medication should be taken at the start of your symptoms B. Rinse you mouth after administering this medication C. Shake the canister prior to administering this medication D. This medication relaxes your airways to decrease your symptoms

B. Rinse you mouth after administering this medication

A nurse is caring for a client who has CF and has a RX for high dose ibuprofen daily. The nurse should identify that which of the following is an expected outcome for the client receiving this medication? A. Thinned pulmonary secretions that are retained in the airways B. Slowed progressions of pulmonary damage C. potentiated action of bronchodilator therapy D. Decreased risk of fevers associated with CF

B. Slowed progressions of pulmonary damage -given to slow the progression of pulmonary damage by suppressing the inflammatory response that causes pulmonary damage

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy and is being discharged. Which of the following referrals should the nurse recommend? A. Spiritual advisor B. Social Worker C. PT D. OT

B. Social Worker

A nurse working in a mental health unit is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider? A. Occupational therapist B. Social worker C. Physical Therapist D. Spiritual support

B. Social worker

A nurse is providing discharge teaching to parents whose infant had a VP shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. We will check his abdomen daily for signs of fluid accumulation B. We will notify the doctor right away if he has a fever C. we should keep a helmet on him when he's awake D. We can expect him to have occasional seizure episodes

B. We will notify the doctor right away if he has a fever - infection is a risk after VP shunt placement

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse perform first? A. Apply mechanical restains to the client B. Administer PRN haloperidol IM to the client C. Approach the client in a non-threatening manner D. Place the client in seclusion

C. Approach the client in a non threatening manner least restrictive priority setting framework

A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. My family cannot commit me because I am homeless B. Even when I'm calm, I'll be forced to take psychotropic medication C. At least 2 doctors must support the commitment D. I am afraid the doctors will make me have surgery

C. At least 2 doctors must support the commitment Involuntary commitment is a court ordered mandate requiring admission of a client to receive mental health services

A nurse is caring for a client who has a RX for clopidogrel. The nurse should monitor the client for which of the following adverse effects? A. Insomnia B. Hypotension C. Bleeding D. Constipation

C. Bleeding - Remeber clopidogrel is an antiplatelet drug

A nurse is caring for a client who has schizophrenia. The client states I like to play ball. Walk down the hall. Be careful not to fall. The nurse should identify that the client is using which of the following? A. pressured speech B. circumstantial speech C. Clang association D. Flight of idea

C. Clang association

A nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicated that the client is physically dependent on the medication? A. exhibits paranioa B. Client reports having insomnia C. Client reports eating excessively D. Client has an increased HR

C. Client reports eating excessively. Amphetamine causes appetite suppression

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the clients brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. Which of the following blood tests should be performed periodically? A. potassium B. Uric acid C. Glucose D. Calcium

C. Glucose at risk for abnormal glucose metabolism

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms A. I just feel so hopeless B. The government has been watching my house C. I am unable to remember to brush my teeth D. I no longer enjoy the activities I used to love

C. I am unable to remember to brush my teeth S/S impaired concentration, judgement and problem solving

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clan association? A. Her mannerologies are poor B. My dog blank a boat to supreme heights C. I can play the flute while wearing a suit. You are cute D. My joints ache. My friend is in the joint

C. I can play the flute while wearing a suit. You are cute

A nurse is caring for a COPD patient and is recieving 2L via nasal. The client is dyspenic and has an oxygen sat of 85%. Which of the following actions should the nurse take? A. Place patient on nonrebreather B. Prepare client for intubation C. Increase oxygen and request an arterial blood gas determination D. Position the client in supine and administer antianxiety

C. Increase oxygen and request an arterial blood gas determination

A nurse is caring for a client who had a stroke and is at risk for falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN RX for restraints

C. Monitor the client at least once every hour - the use of 4 raised side rails on the clients bed is considered a physical restraint that the nurse cannot employ w/out a RX

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal Flaring D. Meconium stools

C. Nasal Flaring

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 nurses priority assessment? A. Perception of reality B. Ability to follow directions C. Physical needs D. Mental status

C. Physical needs Maslow's Hierarchy levels 1. Needs 2. Safety and security 3. love and belonging 4. personal achievement 5. self esteem

A nurse is discussing risk factors for necrotizing enterocolitis in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post term birth B. Macrosomia C. RDS D. Maternal gestational diabetes

C. RDS - RDS is a risk factor for NEC. RD causes intestinal ischemia secondary to hypoxia

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia - Dyspnea, restlessness, HA, and increased BP are indications of impending resp. failure

A nurse on an acute mental health unit is assessing a client who has OCD. Which of the following behaviors should the nurse expect? A. Being intentionally dishonest B. Jumping rapidly between topics of conversations C. Tapping the 4 sides of a light switch D. Mimicking the movements of another person

C. Tapping the 4 sides of a light switch

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. The nurse should identify that these manifestations indicate which of the following adverse effects? A. Akathisia B. Acute dystonia C. Tardive Dyskinesia D. Pseudoparkinsonism

C. Tardive Dyskinesia

A nurse is performing an admission assessment for a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? A. Please try to focus on our conversation B. There is nothing over there except a chair C. Tell me what your are seeing by that chair D. Whatever you are seeing by that chair is not real

C. Tell me what your are seeing by that chair

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. A tornado is going to wipe us all out B. My brain is dead, and my body is slowly rotting away C. The government is after me because I know top secret information D. The TV is purposely playing commercials for products I don't like

C. The government is after me because I know top secret information

A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make? A. This medication is a tricyclic antidepressant and will improve your mood B. This medication is an opioid antagonist that blocks the pleasurable effects of alcohol C. This medication is an antipsychotic that controls manifestations of schizophrenia D. This medication is a cholinesterase inhibitor that slows the progression of dementia

C. This medication is an antipsychotic that controls manifestations of schizophrenia medication is thought to act directly on dopamine receptors in the brain to prevent the reuptake of dopamine, thereby controlling psychotic manifestations

A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, Can I vote in the upcoming presidential election? Which of the following responses should the nurse offer? A. Why do you want to vote? B. I wouldn't worry about voting right now C. We can work together to find out how you can get a mail in ballot D. You'll have a lot more opportunities to vote after you get better

C. We can work together to find out how you can get a mail in ballot

A nurse is assessing a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. I thought i heard something too B. Is someone telling you something? C. What are you hearing? D. There is nobody in that chair for you to listen to

C. What are you hearing? Allows the nurse to find out what the client is hearing without validating the hallucination as real

A nurse is caring for a client who has severe asthma and allergic rhinitis. The client is taking theophylline. Which of the following medications should the nurse identify as being incompatible with theophylline? A. Cromolyn B. Albuterol C. Zafirlukast D. Methylprednisolone

C. Zafirlukast - suppress the metabolism of theophylline which can lead to toxicity

A nurse is reviewing the lab data for a client who is recieving clozapine for schizophrenia. The nurse should identify which of the following findings as a potential adverse effect of the this medication? A. Fasting blood glucose 95 B. Triglycerides 135 C. Total cholesterol 175 D. Absolute neutrophil count 1200

D. Absolute neutrophil count 1200 This is less than the range of 2500 - 8000

A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client? A. Skin will remain intact during hospitalization B. Verbalize one new word each week C. Will begin to help turn himself in bed D. Airway will remain clear as evidenced by clear breath sounds

D. Airway will remain clear as evidenced by clear breath sounds

A nurse is collecting data from a client with schizophrenia who was recently admitted to acute care. Which of the following findings should the nurse expect? A. Seductive behaviors B. Obsession with rituals C. Uncontrolled appetite D. Associative looseness

D. Associative looseness

A nurse is observing a client with schizophrenia in the dayroom. Another client asks him if several items of clothing match. Patient replies " A match. I like matches. They are the givers of light, the light of the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations? A. Clang association B. Echolalia C. Word salad D. Associative looseness

D. Associative looseness a pattern of disordered speech that reflects haphazard and illogical thoughts

A nurse is caring for a client who has schizophrenia. Which of the following statements indicates clang associations? A. I am the king, and everyone should bow to me B. I'm feeling schoomoolizious today C. Option, contrary, moose, allergic D. Basketball in the hall very tall

D. Basketball in the hall very tall

A nurse is caring for a 2 year old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activites would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks

D. Building towers with blocks

A nurse is providing teaching to a class about TIAs. Which of the following pieces of information should the nurse include in the teaching? A. TIA can cause irreversible hemiparesis B. Can be the result of cerebral bleeding C. Cerebral edema D. Can precede an ischemic stroke

D. Can precede an ischemic stroke

A nurse is caring for a client with schizophrenia who is having command hallucinations. Which of the following actions is the priority for the nurse to take? A. Identify triggers that initiate the client's hallucinations B. Administer an antipsychotic medication C. Focus on reality-based orientation D. Determine what the voices are saying

D. Determine what the voices are saying

A nurse is caring for a client who is 12 hrs post-po following a total hip arthroplasty. Which of following medications should the nurse anticipate to administer to this client to prevent DVT? A. Aspirin B. Warfarin C. Ticagrelor D. Enoxaparin (Heparin)

D. Enoxaparin (Heparin)

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. extended periods of sleep B. poor muscle tone C. RR 50 D. Exaggerated reflexes

D. Exaggerated reflexes - exhibits clinical findings of hyperactivity within the CNS

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first? A. Teach the client strategies to decrease the hallucinations B. Identify whether the client is on antipsychotic medications C. Distract the client from the hallucinations D. Explore what the voices are saying to the client.

D. Explore what the voices are saying to the client.

A nurse is admitting a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? A. Anhedonia B. Avolition C. Flat effect D. Hallucinations

D. Hallucinations

A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all abdominal quads B. Passage of blood-tinged liquid stool C. Presence of flatus D. Hyperactive bowel sounds above the obstruction

D. Hyperactive bowel sounds above the obstruction

A nurse is caring for a client with BPH who has a new RX for doxazosin. Which of the following manifestations should the nurse monitor for as an adverse effect of doxazosin? A. seizures B. Tachycardiac C. Bronchodilation D. Hypotension

D. Hypotension

A nurse is caring for a client who has schizophrenia. The client tells the nurse that he is hearing voices in his head telling him to purchase a knife today. He knows that this knife will make him do bad things. which of the following responses should the nurse make? A. Why do you think the voices want you to buy a knife? B. Do you already own any knives C. When the voices speak, do you always do what they say? D. I dont hear any voices, just yours and mine. But I understand that you are fearful

D. I dont hear any voices, just yours and mine. But I understand that you are fearful

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effect from the error. What is the purpose of completing the incident report? A. Alerting the facility administration of a possible litigation situation B. Tracking employee performance for possible disciplinary action C. Providing a detailed report of the occurrence for the client's families D. Identifying situations that contribute to the occurrence of medication errors

D. Identifying situations that contribute to the occurrence of medication errors

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A Can you tell me why you do not want to participate int he planned group activity B. Do you understand that psychotropic medications cause weight gain C. The aerobics class will be more effective at burning calories than walking D. It sounds like you have come up with an alternative exercise that works for you

D. It sounds like you have come up with an alternative exercise that works for you

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? A. Prevent depression in the client B. Refer the client to OT C. Support the family of the client D. Monitor the client for increased intracranial pressure

D. Monitor the client for increased intracranial pressure

A nurse is assessing a client who has schizophrenia. The client states " I need to get my gummamoshu from by my house". The nurse recognizes this statement as an example of which of the following? A. Flight of ideas B. Echolalia C. Perseveration D. Neologism

D. Neologism

A nurse is planning care for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Avoid the use of facial gestures when speaking to the client B. Speak to the client in a loud tone C. Use child like phrases to help the client understand commands D. Offer pictures for the client to point to as an alternative form of communication.

D. Offer pictures for the client to point to as an alternative form of communication.

A nurse is caring for a client who has COPD and is experiencing SOB. Which of the following actions shouyld the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed lip breathing D. Place the client in an upright position

D. Place the client in an upright position

A nurse is caring for a pregnant client who is 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. perform an amnioinfusion D. Prepare for delivery of the infant

D. Prepare for delivery of the infant - delivery is considered when a biophysical score is lower than 6

A nurse is caring for a client who is experiencing an acute asthma exacerbation. Which of the following medication should the nurse identify as being contraindications for this client? A. Dextromethorphan B. Montelukast C. Ciprofloxacin D. Propranolol

D. Propranolol

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of QSEN initiative? A. Safety B. Informatics C. Patient-centered care D. Quality improvement

D. Quality improvement

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect A. Spasticity of the left foot B. Negative babinski reflex C. Ocular HTN D. Right sided hemiplegia

D. Right sided hemiplegia

A nurse in an acute mental health facility is reviewing the medication records of a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? A. Postpartum depression B. Schizophrenia C. Obesity D. Severe Alzheimer's

D. Severe Alzheimer's Medication is an NMDA receptor agonist, it slows the progression of manifestations and improves cognitive functions

A nurse is providing teaching to the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. We will not set time limits for discussing her delusions B. We will avoid reacting to her command hallucinations C. She might lose weight due to her medications D. She might be having a relapse if she stops attending social events.

D. She might be having a relapse if she stops attending social events

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired Memory C. Dysphoria (state of unease) D. Social Discomfort

D. Social discomfort Negative symptom is the absence of something that should be present

A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication? A. Urine specific gravity B. Urine output C. Blood pressure D. Temperature

D. Temperature Antipsychotic medications can cause agranulocytosis, which is the depletion of WBCs which increases the risk for infection. A fever is an early detection to check WBC

A nurse is caring for a client who has schizophrenia. The client states Aliens came into my room last night and took a sample of my blood. Which of the following responses should the nurse make? A. Aliens do not exist B. HAs your daughter had her baby C. Do you mean o say a lab tech came and drew your blood last night D. That does not sound real

D. That does not sound real This statement allows for the client to expand upon the earlier statement, which allows exploration of the clients thought process

A nurse is caring for a client who has schizophrenia and is admitted to the mental health unit. The client has history of aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A. Its a beautiful day outside. Lets take a walk B. Sit down and we'll try try out a relaxation exercise C. Would you like you anti anxiety medication now D. You are pacing back and forth. Can you tell me what you are feeling?

D. You are pacing back and forth. Can you tell me what you are feeling?

A nurse is caring for a client who has schizophrenia and is being discharged from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventive mental health groups C. enroll the client in a 12 step program D. contact an intensive outpatient program

D. contact an intensive outpatient program

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. blurred vision B. Urinary retention C. Muscle flaccidity D. elevated temperature

D. elevated temperature S/S rigidity, sweating, dysrhythmias, and fluctuations in blood pressure