hi

a nurse is planning care for a new admit client with bipolar disorder and is experiencing mania. which is the priority action?

provide frequent high calorie snacks

nurse receives change of shift report. which client should nurse assess first?

pt experiencing delusions of persecution

a nurse is caring for a child who has conduct disorder and is behaving in destructive manner. which therapeutic nursing intervention is priority?

reduce environmental stimuli

a nurse in a community health center is counseling a family of two parents and two children. which of the following statement by a family member indicates manipulative behavior?

"if you do hw for me, i wont bother you for the rest of the day"

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 childs surrounding

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?

Able to go to work every day so I dont have a problem

nurse is teaching a group of new licensed nurses about use of mechanical restraints. which of the following info should the nurse include?

Apply restrains when other means have failed

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 if they have questions or thoughts

a nurse is creating plan of care for client who has been placed in seclusion. which intervention should nurse include?

renew prescription every 4 hrs

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

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 occurence to charge nurse

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following clients behaviors indicates effectiveness of the therapy?

refrains from manipulating others to earn dining room privileges

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

HTN

a nurse is teaching the guardians of a client about their adolescents childs diagnosis of bulimia nervosa. which statement by the guardian indicates understanding?

regular dental check ups

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

Sodium level 128

nurse is reviewing lab results of a schizo client taking clozapine. what lab value is a contraindication?

WBC 2500

nurse reviewing med admin record for a client who is experiencing adverse effects of chloropromazine. the nurse should administer benzotropine to relieve which adverse effect?

acute dystonia?

a nurse notices client appears withdrawn and fearful. to establish trusting nurse client relationship, the nurse should take which action?

admission is confidential

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 towards animals

a client who has a diagnosis of depression is attending group therapy. during the meeting the nurse asks each member to identify one goal for the day. when it's the clients turn, they do not respond. which action should the nurse take before repeating the request to the client?

allow client time to formulate an answer

nurse is caring for older adult client experiencing delirium. which intervention should be in plan of care?

allow client to perform daily rituals to decrease anxiety

a nurse is assessing a client who has schizophrenia. which of the following findings should the nurse document as a negative symptom of the disorder?

anhedonia

a nurse observes a client pushing on the locked unit door. which statement should nurse make?

appears you want to open the door

a nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. which intervention is the priority?

arrange one to one observation

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 client what voices are saying

a nurse is facilitating a community meeting for acute care clients. one client constantly talks. which intervention should nurse implement?

ask other group members to discuss their feelings about clients monopolizing behavior

a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. the nurse should identify which treatment options can offer interdisciplinary services for client at home>

assertive community treatment

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 should the nurse take?

assess client for perceptual disturbance

a nurse is caring for a client who is experiencing a panic attack. which action should nurse take?

assist client with deep breathing

a nurse in a mental health facility is planning discharge for a client who has a hx of alcohol use disorder. which of the following postdischarge activities should the nurse include?

attending a relapse prevention group

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 in a mental health clinic is planning care for a client who has new prescription for olanzapine. which intervention is the priority?

avoid driving during initial therapy

a nurse in an ED is caring for 4 clients. which client is nurse required to report as victim of abuse?

older client bedbound who has stage 4 pressure ulcer

a nurse is assessing a client who sustained injuries 12 hrs ago following MVA. clients BAC is 325. which finding should indicate client is experiencing alcohol withdrawal?

blood pressure 154/96

a nurse is assiting a client who has a terminal illness adjust to progressive loss of independence. which statement by client indicates acceptance of illness?

order wheelchair when unable to walk

a nurse observes a client who has acute mania hit another client. which action should the nurse take

call for a team of staff members to help with the situation

a nurse is delegating client care tasks to a LPN and an AP. which of the following tasks should the nurse assign the LPN?

change the dressing of the client who has superficial wound

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 "im red in the head and im going to bed!" the nurse should documents the speech pattern as which?

clang association

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

client administered one half of the prescribed dose of medication

a charge nurse on a mental health unit is discussing client rights with new nurse

client admitted involuntarily have the right to give consent for procedures

a nurse is assessing a client for risk factors for the development of depression. which factor places the client at an increased risk?

client has COPD

during a clients initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning towards. which of the following assumptions should the nurse make based on the clients nonverbal behaviors?

client interested in what the nurse is saying

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?

client needs excessive external input to make everyday decisions

a nurse is caring for a client who is experiencing a situational crisis. which finding should the nurse expect?

client recently lost a grandparent in a MVA

a nurse is caring for a client who has borderline personality disorder. which of the following goals is the priority?

client refrains from self mutilation

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which finding should the nurse notify?

client reports an inability to breathe easily

a nurse is discussing a 12 step program for alcohol use disorder patient and is in an acute care facility undergoing detox. which info should nurse include in teaching?

client should obtain sponsor

Nurse caring for a group of clients. which finding should the nurse report?

client taking lamotrigine and has developed a rash

a nurse is caring for 4 clients in ED. which client CAN give informed consent?

client who has major depressive disorder

a nurse is caring for a group of clients. which of the following findings is the nurse required to report?

client with bipolar threatens to harm roommate

a nurse is receiving report on 4 clients. who should she see first?

clozapine with sore throat and chills

a nurse is caring for a schizophrenic patient. which finding places the client at great risk of injury

command hallucinations

a nurse is admitting a female client who has anorexia nervosa. which of the following manifestations should the nurse expect?

orthostatic hypotension

a nurse is admitting a client who has major depressive disorder and a new prescription of tranylcypromine. which OTC med can give adverse event?

phenylephrine

a nurse in a providers 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?

dark urine

a nurse in an ED is admitting a client who reports experiencing a headache and heart palpitations after having a glass of win 1 hr ago. the client has a hx of depression and blood pressure of 210/105 and temp of 103.8. which action should the nurse take first?

determine clients prescribed medicine regimen

a nurse is caring for a client who is experiencing alcohol withdrawal. which of the following medications should the nurse administer first?

diazepam

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 attempts 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 lorazepam

a nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. which info about relapse should nurse include?

early identification of changes such as decreased social involvement is important

a nurse is planning care for a client who has depression and has made frequent suicide attempts. which of the following indicates decreased risk of suicide?

easier to talk about feelings now

a nurse is performing a cognitive assessment to distinguish delirium from dementia.

easily distracted

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 medication?

eat regular diet with normal salt and fluids

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 client to drink 125 ml of fluid each hour while awake

a nurse is planning prevention strategies for partner violence in the community. which strategy should nurse include in secondary prevention?

establish screening programs

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?

event of client threatening to harm others, medications can be administered without consent

a nurse is teaching a client who has depressive disorder about fluoxetine. which of the following info should the nurse include in the teaching?

experience sexual dysfunction

a nurse is teaching families of clients who have PTSD about expected clinical manifestations.

experiences feelings of isolation

a nurse is talking with a group of parents who have recently experienced the death of a child. which action should nurse take?

form a weekly support group

a nurse is planning care for a client who is experiencing acute mania. which intervention promotes sleep?

frequent rest periods during the day

a nurse is caring for a client who has a recent diagnosis of mild alzheimers disease. the clients 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 nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

promote music

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

gather endotracheal intubation supplies

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

given to reduce muscle movements during therapy

a nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. which behavior is priority to report?

giving away possessions

a nurse is assessing a client who has major depressive disorder and been receiving amitripyline for 1 week. which outcome should nurse expect?

greater risk of attempting suicide

a nurse is working with a group of clients who have PTSD. which intervention should nurse include to reduce anxiety?

guided imagery

a nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 wks ago. the nurse should recognize which of the following as an expected adverse effect that might cause the client to stop taking the medication?

hand tremors

a nurse is planning care for a client with bipolar disorder and is experiencing mania which intervention should be in plan of care?

high calorie finger foods

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?

hopelessness anhedonia flat facial expression

a nurse in a clinic is assessing a client whose partner died 4 mos ago. which of the following statements indicates that the client is at risk for complicated grief?

i feel so empty without with my wife that its hard to get up every morning

a nurse is updating plan of care for a client with bulimia nervosa and is 5% above ideal body weight. which intervention should the nurse include?

identify clients trigger foods

a nurse is caring for a client who is in an abuse relationship and is assisting in the development of a safety plan. which action is the first component of a safety plan?

identify signs of escalation of violence

a nurse is caring for a client who gave birth to a stillborn baby. which statement should nurse make?

ill stay with you in case you want to talk

a nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. which finding should partner report?

inability to sleep

home health nurse is assessing older adult client whose sibling is the primary care giver. which finding indicates possible neglect?

inappropriate dress

a nurse is caring for a client who has alcoholic cardiomyopathy. which of lab findings should nurse expect

increased CPK

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 client in private setting

a school nurse is assessing a school age child who experienced loss of a parent 8 mos ago. which finding indicates PTSD?

lack of interest of upcoming holiday

a nurse is educating the parent of a child who has a new diagnosis of autism. which manifestation should be taught?

language delay

a nurse is caring for an older adult client who begins to cry and states i knew god would punish me and i deserve this.. which response should the nurse make?

lets talk about what is upsetting you

a nurse is planning care for a client who has generalized anxiety disorder. which level of anxiety should nurse plan to teach relaxation techniques?

mild

a nurse is planning care for client who is to undergo ECT. which action should be in plan of care?

monitor clients cardiac rhythm during treatment

a clietn who has bipolar depression is placed in room with client who has severe depression. client wakes up depressed client. what do you do?

move bipolar pt to private room

a nurse is planning care for a client who has made repeated physical threats. client doesnt want to leave but nurse requests the provider transfer patient to another unit. which ethical principle is nurse applying?

nonmaleficence

a nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. the nurse should identify that which statement indicates clients partners understanding

not take charge of partners work responsibilities

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

not uncommon to feel angry towards self

nurse is preparing to discharge home an older adult client who attempted suicide. the client lives alone and has difficulty performing ADLs. which referral should nurse indicate?

occupational therapy meal delivery services physical therapy home health services

a nurse is assessing family dynamics. which indicates boundary issue?

older children responsible for younger siblings

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?

reports commands hallucinations

A nurse is discussing the home care of a client who has advanced alzheimers disease with the clients partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver?

respite care

nurse is assessing a client who is experiencing opioid withdrawal. which manifestation should the nurse expect?

rhinorrhea

a nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining of weight. which statement is summarizing?

saying you are fat and using laxatives because afraid of gaining weight

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 clients behavior

a nurse in an ED is caring for a female adolescent who has bulimia nervosa and had a fainting episode. which statement by parent acknowledged clients diagnosis?

she wont let me take the trash from her room. im concerned

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 benztropine 2 mg IM?

shuffling gait

a nurse on a mental health unit is caring for a group of clients. which of the following actions is an example of the ethical principle of justice

spending time with verbally abusive pt

a nurse in an outpatient mental health setting is collecting a health hx 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 that med?

st johns wort

a nurse is planning care for 4 clients. which task should be given to AP?

stay with anorexia nervosa client 1 hr after mealtime

a nurse is caring for a PTSD patient after returning home from deployment. which is priority action?

stay with client when flashbacks occur

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk of depression?

substance abuse disorder

a nurse is caring for a child who is taking methylphenidate. nurse should monitor for which adverse effect?

tachycardia

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 action should the nurse take

talk about activities that the client enjoyed with their partner

nurse teaching coping strategies to a client who is experiencing depression related to partner violence. which statement indicates clients understanding?

talk to close friend about feelings

nurse is assessing a client who has bulimia nervosa, which finding should be expected?

tooth erosion

a nurse is reviewing the medical record of a client who has anorexia nervosa. which finding identifies indication of hospitalization?

tot body fat 8.7%

a nurse is interviewing an older adult client. which action should the nurse plan to take?

use screening tools for depression

nurse teaching new licensed nurse about care plans for clients who have depressive disorders which statement indicates understanding of teaching?

will update plan of care as manifestations change