Leadership exam 3

. Which statement best describes the role of the parish nurse? 1. The parish nurse practices holistic healthcare within a faith community. 2. The parish nurse cares for clients in a religious-based hospital. 3. The parish nurse practices nursing in a parish clinic. 4. The parish nurse is a licensed practical nurse (LPN) who cares for clients in the home.

1

A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement? 1. Tell the HCP that the jokes are inappropriate and offensive. 2. Report the behavior to the medical staff committee. 3. Discuss the problem with the chief nursing officer. 4. Call a Code Purple and have the nurses surround the HCP.

1

The charge nurse has assigned the licensed practical nurse (LPN) to administer medications to the clients on an inpatient psychiatric unit. Which client should the LPN force to take the prescribed medications? 1. The client with bipolar disorder who has been declared incompetent in a court of law. 2. The client with major depression who voluntarily admitted herself to the unit. 3. The client with paranoid schizophrenia who was involuntarily admitted to the unit. 4. The client with a borderline personality who has legal charges pending in the court.

1

The charge nurse in an extended care facility notes an elderly male resident holding hands with an elderly female resident. Which intervention should the charge nurse implement? 1. Do nothing, because this is a natural human need. 2. Notify the family of the residents about the situation. 3. Separate the residents for all activities. 4. Call a care plan meeting with other staff members.

1

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? 1. The client diagnosed with dementia who is confused and disoriented. 2. The client diagnosed with schizophrenia who is experiencing tardive dyskinesia. 3. The client diagnosed with bipolar disorder who has a lithium level of 2.0 mEq/L. 4. The client diagnosed with chronic alcoholism who is experiencing delirium tremens.

1

The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee? 1. Discuss the nurse's actions with the unit manager. 2. Confront the nurse about the behavior. 3. Do not allow the nurse to take breaks alone. 4. Prepare an occurrence report on the employee.

1

The client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight (IBW) for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement? 1. Notify the psychiatrist to request a court order to feed the client. 2. Take no action because the client has the right to refuse treatment. 3. Discharge the client because she is not complying with the treatment. 4. Physically restrain the client and insert a nasogastric tube for feeding

1

The client diagnosed with schizophrenia is being seen by the psychiatric clinic nurse for the initial visit. Which intervention should the nurse implement first? 1. Develop a trusting nurse/client relationship. 2. Determine the client's knowledge of medication. 3. Assess the client's support systems. 4. Allow the client to vent their feelings.

1

The client in the psychiatric unit tells the nurse, "Someone just put a bomb under the couch in the lobby." Which action should the nurse implement first? 1. Look under the couch for a bomb. 2. Implement the bomb scare protocol. 3. Have the staff evacuate the unit. 4. Tell the client there is no bomb.

1

The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first? 1. Determine whether the client has grab bars in the bathroom. 2. Encourage the client to take a shower instead of a bath. 3. Initiate a referral to a physical therapist for the client. 4. Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

1

The clinical manager wants to reward the staff on the psychiatric unit for having no tardies or absences for 1 month. Which action would be most appropriate for the clinical manager? 1. Provide pizza, drinks, and dessert for all the shifts. 2. Post a thank you note on the board in the employee lounge. 3. Individually acknowledge this accomplishment with the staff. 4. Place official documentation in each staff's employee file.

1

The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first? 1. Tell the man the client needs to go to the x-ray department. 2. Notify hospital security and have the man removed from the room. 3. Explain that the man must leave the room while the nurse checks the client. 4. Give the client a brochure with information about a woman's shelter

1

The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? 1. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough. 2. The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds. 3. The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer. 4. The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis.

1

The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the nurse the client is really agitated and anxious, and has slurred speech. Which intervention should the nurse implement first? 1. Assess the client for heroin withdrawal. 2. Ask the UAP to take the client's vital signs. 3. Notify the client's healthcare provider. 4. Administer chlordiazepoxide (Librium), an antianxiety medication.

1

The mental health worker (MHW) has tried to calm down the client on the psychiatric unit who is angry and attempting to fight with another client. The nurse observes the MHW "taking down" the client to the floor. Which intervention should the nurse implement? 1. Assist the MHW with the "take down" of the client. 2. Call the hospital security to come and assist the MHW. 3. Document the client "take down" in the nurse's notes. 4. Remove the other clients from the day room area.

1

The newborn nursery nurse has received report. Which client should the nurse assess first? 1. The 2-hour-old infant who has nasal flaring and is grunting. 2. The 6-hour-old infant who has not passed meconium stool. 3. The 12-hour-old infant who refuses to latch onto the breast. 4. The 24-hour-old infant who has a positive startle reflex.

1

The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? 1. Administer PO medications to a client diagnosed with gastroenteritis. 2. Take the routine vital signs for all the clients on the pediatric unit. 3. Transcribe the HCP's orders into the computer. 4. Assess the urinary output of a client diagnosed with nephrotic syndrome.

1

The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? 1. Evaluate the job performance of the staff. 2. Be the sole decision maker for the unit. 3. Take responsibility for the staff nurse's actions. 4. Attend the medical staff meetings

1

The nurse has received the shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom. 2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. 3. The client diagnosed with pancreatitis who wants the nasogastric tube removed. 4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

1

The nurse is caring for clients in the psychiatric unit. Which task would be most appropriate for the nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to walk with the client who is agitated and anxious. 2. Ask the MHW to clean up the floor where the client has urinated. 3. Tell the MHW to phone the HCP to obtain a PRN medication order. 4. Request the MHW to explain seizure precautions to another staff member.

1

The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first? 1. Pre-medicate the client with a narcotic analgesic. 2. Prepare the equipment and bandages at the bedside. 3. Remove the old dressing with non-sterile gloves. 4. Place a sterile glove on the dominant hand.

1

The psychiatric nurse and mental health worker (MHW) on a psychiatric unit are caring for a group of clients. Which nursing task should the nurse delegate to the MHW? 1. Take the school-aged children to the on-campus classroom. 2. Lead a group therapy session on behavior control. 3. Explain the purpose of recreation therapy to the client. 4. Give a bipolar client a bed bath and shampoo the hair.

1

The psychiatric nurse overhears a mental health worker (MHW) arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement? 1. Ask the MHW to go to the nurse's station. 2. Tell the MHW to quit arguing with the client. 3. Notify the clinical manager of the psychiatric unit. 4. Report this behavior to the client abuse committee.

1

The unlicensed assistive personnel (UAP) accidentally pulled the client's chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? 1. Securely tape petroleum gauze over the insertion site. 2. Instruct the UAP how to move a client with a chest tube. 3. Assess the client's respirations and lung sounds. 4. Obtain a chest tube and a chest tube insertion tray.

1

The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound. 2. Keep the resident's heels off the surface of the bed. 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake.

1

The client diagnosed with paranoid schizophrenia is imminently aggressive and is dangerous to himself, the other clients, and the psychiatric staff members. The client is placed in a seclusion room. Which interventions should the psychiatric nurse implement? Select all that apply. 1. Assess the client every 2 hours for side effects of medication. 2. Tell the client what behavior will prompt the release from seclusion. 3. Do not notify the client's family of the initiation of seclusion. 4. Explain that the client will be in the seclusion room for 24 hours. 5. Instruct the MHW to check the client every 10 to 15 minutes.

1, 2, 5

The client with long-term alcoholism asks the nurse, "How does Alcoholics Anonymous help me quit drinking?" Which statements are the nurse's best responses? Select all that apply. 1. "AA has sponsors whom you can contact if you want to take a drink." 2. "AA discusses medications used to help prevent drinking alcohol." 3. "AA is a support group of alcoholics who have successfully quit drinking." 4. "AA helps you realize the power you have over your addiction to alcohol." 5. "AA has professional guest speakers to address addictive personalities."

1, 3

During an interview, the female client tells the psychiatric nurse in a mental health clinic, "Sometimes I feel like life is not worth living. I am going to kill myself." Which interventions should the nurse implement? Select all that apply. 1. Make a no-suicide contract with the client. 2. Place the client on a 1-to-1 supervision. 3. Ask the client whether she has a plan. 4. Commit the client to the psychiatric unit. 5. Assess the client's support system.

1, 3, 5

The unconscious 4-year-old child with bruises covering the torso in varying stagesof healing is brought to the emergency department by paramedics. The nurse notes small burn marks on the child's genitalia. Which actions should the nurse implement? Select all that apply. 1. Notify Child Protective Services. 2. Ask the parent how the child was injured. 3. Perform a thorough examination for more injuries. 4. Tell the parents that the police have been called. 5. Prepare the child for skull x-rays and a CT scan.

1, 3, 5

The nurse is preparing to administer the client's first intravenous antibiotic. Prioritize the nurse's actions from first (1) to last (5). 1. Check the healthcare provider's order in the chart. 2. Determine if the client has any known allergies. 3. Hang the secondary IV piggyback higher than the primary IV. 4. Set the intravenous pump at the correct rate. 5. Determine if the antibiotic is compatible with the primary IV.

1, 5, 2, 3, 4

The 36-year-old client in the women's health clinic is being prescribed birth control pills. Which information is important for the nurse to teach the client? Select all that apply. 1. Do not smoke while taking birth control pills. 2. Take one pill at the same time every day. 3. If a birth control pill is missed, do not double up. 4. Stop taking the pill if breakthrough bleeding occurs. 5. There can be interactions with other medications.

1,2,5

The nurse manager of the maternal-child department is developing the budget for the next fiscal year. Which statement best explains the first step of the budgetary process? 1. Ask the staff for input about needed equipment. 2. Assess any new department project for costs. 3. Review the department's current year budget. 4. Explain the new budget requirements to the staff.

1,3

The labor and delivery nurse has assisted in the delivery of a 37-week fetal demise. Which intervention should the nurse implement? 1. Remove the baby from the delivery area quickly. 2. Tell the father to arrange to take the infant home. 3. Wrap the infant in a towel and place it aside. 4. Obtain a lock of the infant's hair for the parents.

1,4

The family member of a client in a long-term care facility is unhappy with the care being provided for the loved one. Which person would be most appropriate to investigate the complaint and report the findings during a client care conference? 1. The ombudsperson for the facility. 2. The social worker for the facility. 3. The family member who is unhappy. 4. The director of nurses.

1. An ombudsman is a representative appointed to receive and investigate complaints made by individuals of abuses or capricious acts. All Medicare and Medicaid long-term care facilities must have an ombudsman to act as a neutral party in matters of dispute with the facility. This is the best person to investigate a complaint.

The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering? 1. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery. 2. The anticoagulant enoxaparin (Lovenox) to a client who had a TKR. 3. The sliding scale insulin Humalog to a client who had a Whipple procedure. 4. The aminoglycoside vancomycin to a client allergic to the antibiotic penicillin.

1. Antiplatelet medication will increase the client's bleeding time and should be held 5 days prior to surgery; therefore, this medication should be questioned.

The charge nurse overhears two unlicensed assistive personnel (UAPs) discussing a client in the hallway. Which action should the charge nurse implement first? 1. Remind the UAPs that clients should not be discussed in a public area. 2. Tell the unit manager that the UAPs might have been overheard. 3. Have the UAPs review policies on client confidentiality and HIPAA. 4. Find some nursing tasks the UAPs can be performing at this time.

1. The charge nurse should remind the UAPs not to discuss confidential information in a public place. This is the first action.

The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client? 1. Restrain the client's wrists, as needed. 2. Offer the client fluids every 2 hours. 3. Apply a hand mitt to the arm opposite the IV site for 12 hours. 4. Check circulation of the restrained limb every 2 hours.

1. The client cannot be restrained as needed. The nurse must have documentation for the need and an HCP's specific order that includes reason for restraint and time limited to no more than 24 hours. This HCP order should be clarified.

The resident in a long-term care facility tells the nurse, "I think my family just put me here to die because they think I am too much trouble." Which statement is the nurse's best response? 1. "Can you tell me more about how you feel since your family placed you here?" 2. "Your family did what they felt was best for your safety." 3. "Why would you think that about your family? They care for you." 4. "Tell me, how much trouble were you when you were at home?"

1. The client is expressing negative feelings about being placed in the nursing home. Asking about the client's feelings is a therapeutic response that encourages the client to discuss his or her feelings.

Which situation should the charge nurse in the critical care unit address first after receiving the shift report? 1. Talk to the family member who is irate over his loved one's nursing care. 2. Complete the 90-day probationary evaluation for a new ICU graduate intern. 3. Call the laboratory concerning the type and crossmatch for a client who needs blood. 4. Arrange for a client to be transferred to the telemetry step-down unit.

1. This situation should be addressed first because the charge nurse is responsible for family/client complaints. If the family contacts the administration, the charge nurse must be aware of the situation.

. The mental health worker (MHW) reports that one of the nurses threatened to forcefeed the male client diagnosed with schizophrenia if the client did not eat the meal on the lunch tray. Which action should the charge nurse take first? 1. Tell the MHW that this intervention is part of the client's care plan. 2. Request the nurse to come to the office and discuss the MHW's allegation. 3. Ask the client what happened between him and the nurse during lunch. 4. Ask the MHW to write down the situation to submit to the head nurse.

2

. Which client should the nurse in the post-anesthesia care unit (PACU) assess first? 1. The client who received general anesthesia who is complaining of a sore throat. 2. The client who had right knee surgery and has a pulse oximeter reading of 90%. 3. The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse. 4. The client who had abdominal surgery and has green bile draining from the N/G tube.

2

A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse's station saying, "I am Joey's father; can you tell me how he is doing?" Which statement is the nurse's best response? 1. "Your son has a fractured jaw and some bruises but he is doing fine." 2. "I am sorry I cannot give you any information about your son." 3. "You should go talk to your wife about your son's condition." 4. "The social worker can discuss your son's condition with you."

2

The 32-year-old male client with a traumatic right above-the-elbow amputation tells the home health (HH) nurse he is worried about supporting his family and finding employment since he can't be a mechanic anymore. Which intervention should the nurse implement? 1. Contact the HH agency's occupational therapist. 2. Refer the client to the state rehabilitation commission. 3. Ask the HH agency's social worker about disability. 4. Suggest he talk to his wife about his concerns.

2

The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? 1. Tell the unlicensed assistive personnel (UAP) to ambulate the client with the walker. 2. Request a referral to the physical therapy department. 3. Obtain a walker that is appropriate for the client's height. 4. Notify the social worker of the HCP's order for a walker.

2

The HH aide calls the HH nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Visit the client to assess the reddened area. 3. Document the finding in the client's chart. 4. Refer the client to the wound care nurse.

2

The charge nurse received laboratory data for clients in the psychiatric unit. Which client data warrants notifying the psychiatric healthcare provider? 1. The client on lithium (Eskalith) whose serum lithium level is 1.0 mEq/L. 2. The client on clozapine (Clozaril) whose white blood cell count is 13,000. 3. The client on alprazolam (Xanax) whose potassium level is 3.7 mEq/L. 4. The client on quetiapine (Seroquel) whose glucose level is 128 mg/dL.

2

The chief nursing officer (CNO) of an extended care facility is attending shift report with two charge nurses, and an argument about a resident's care ensues. Which action should the CNO implement first? 1. Ask the two charge nurses to stop arguing and go to a private area. 2. Listen to both sides of the argument and then implement a plan of care. 3. Ask the family to join the discussion before deciding how to implement care. 4. Tell the nurses to stop arguing and continue to give report.

2

The client diagnosed with a somatization disorder is complaining of vomiting, having diarrhea, and having a fever. Which intervention should the nurse implement first? 1. Assess the client's anxiety level on a scale of 1 to 10. 2. Check the client's vital signs. 3. Discuss problem-solving techniques. 4. Notify the client's healthcare provider.

2

The client on a psychiatric involuntary admission is threatening to run away from the unit. Which intervention should the nurse implement first? 1. Notify the police department of the client's threats. 2. Place the unit on high alert for unauthorized departure. 3. Talk to the client about the threat of running away. 4. Have the client sign out against medical advice (AMA).

2

The client seeing the psychiatric nurse in the mental health clinic tells the nurse, "If I tell you something very important, will you promise not to tell anyone?" Which statement is the nurse's best response? 1. "I promise I will not tell anyone if you don't want me to." 2. "If it affects your care I will have to tell someone who can help." 3. "If you don't want me to tell anyone, then please don't tell me." 4. "Why do you not want me to tell anyone if it is so important?"

2

The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first? 1. The 4-year-old child who fell and is complaining of left leg pain. 2. The 3-year-old child who is drooling and does not want to swallow. 3. The 8-year-old child who has complained of a headache for 2 days. 4. The 10-year-old child who is thirsty all the time and has lost weight.

2

The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1? 1. The client with head trauma whose pupils are fixed and dilated. 2. The client with compound fractures of the tibia and fibula. 3. The client with a sprained right wrist with a 1-inch laceration. 4. The client with a piece of metal embedded in the right eye.

2

The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? 1. Have another employee drive the clients home. 2. Notify the public health department immediately. 3. Send the clients to the emergency department. 4. Obtain stool specimens from the clients.

2

The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? 1. Immediately give a 2-week notice and find a different job. 2. Discuss the situation with the manager who interviewed him. 3. Talk with the other employees about the staffing situation. 4. Tell the charge nurse the staffing is not what was explained to him.

2

The hospital will be implementing a new medication administration record (MAR) for documenting medication administration. Which action should the clinical manager take first when implementing the new MAR? 1. Discuss the new MAR with each nurse individually. 2. Schedule meetings on all shifts to discuss the new MAR. 3. Require the nurse to read a handout explaining the new MAR. 4. Ask the nurses to watch a video explaining the new MAR.

2

The male client in the psychiatric unit asks the MHW to mail a letter to his family for him. Which action would warrant intervention by the psychiatric nurse? 1. The MHW tells the client to place the letter in the mailbox. 2. The MHW informs the client he cannot send mail to his family. 3. The MHW takes the letter and places it in the unit mailbox. 4. The MHW reports the client mailed a letter at the team meeting.

2

The mother of a client recently diagnosed with schizophrenia says to the nurse, "I was afraid of my son. Will he be all right?" Which response by the psychiatric nurse supports the ethical principal of veracity? 1. "I can see your fear; you are concerned your son will not be all right." 2. "If your son takes medication, the symptoms can be controlled." 3. "Why were you afraid of your son? Did you think he would hurt you?" 4. "Schizophrenia is a mental illness and your son will not be all right."

2

The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon? 1. The client who is 2 days postoperative for bowel resection and who refuses to turn, cough, and deep breathe. 2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away. 3. The client who is 2 hours postoperative for TKR and who has 400 mL in the cell-saver collection device. 4. The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign.

2

The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney. 2. Review the client's chart. 3. Purchase personal liability insurance. 4. Discuss the case with the supervisor.

2

The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first? 1. The female client diagnosed with histrionic personality disorder who needs to talk to the nurse about something very important. 2. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. 3. The male client diagnosed with major depression whose wife called and said he was talking about killing himself. 4. The client diagnosed with bipolar disorder who is manic and has not slept for the last 2 days.

2

The nurse is caring for a female client 3 days post-knee replacement surgery when the client complains of vaginal itching. The medication administration report (MAR) indicates the client has been receiving the antacid calcium carbonate (Maalox), the antibiotic ceftriaxone (Rocephin), and the anticoagulant enoxaparin (Lovenox). Which priority intervention should the nurse implement? 1. Request the dietary department to send yogurt on each tray. 2. Explain to the client this is the result of the antibiotic therapy. 3. Notify the HCP on rounds of the client's vaginal itching. 4. Ask the client whether she is having unprotected sexual activity.

2

The nurse is caring for clients in an outpatient psychiatric clinic. Which client would the nurse discuss with the healthcare provider? 1. The client diagnosed with bipolar disorder who is receiving carbamazepine (Tegretol), an anticonvulsant. 2. The client diagnosed with schizophrenia who reports taking the antacid Maalox daily for heartburn. 3. The client diagnosed with major depression who is receiving isoniazid (INH), an antituberculosis medication. 4. The client diagnosed with anorexia nervosa who is receiving amitriptyline (Elavil), a tricyclic antidepressant.

2

The nurse is in the middle/working phase of the nurse/client relationship. Which statement is a task in the orientation phase? 1. Identify the client's strengths and weaknesses. 2. Help the client identify problem-solving techniques. 3. Evaluate the client's experience while in the group. 4. Establish the rules for how the meetings will be conducted

2

The nurse is taking a history on a client in a women's clinic when the client tells the nurse, "I have been trying to get pregnant for 3 years." Which question is the nurse's best response? 1. "How many attempts have you made to get pregnant?" 2. "What have you tried to help you get pregnant?" 3. "Does your insurance cover infertility treatments?" 4. "Have you considered adoption as an option?"

2

The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess? 1. Why the client did not have a viable baby with the first pregnancy. 2. If the mother received a Rhogam injection after the last pregnancy. 3. The period of time between the client's pregnancies. 4. When the mother terminated the previous pregnancy.

2

The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? 1. Place a Posey vest restraint on the client. 2. Move the client to a room near the station. 3. Ask the HCP for an antipsychotic medication. 4. Raise all four side rails on the client's bed.

2

The psychiatric clinic nurse is returning telephone calls. Which telephone call should the nurse return first? 1. The female client who reports being slapped by her husband when he got drunk last night. 2. The male client who reports he is tired of living, since his wife just left him because he lost his job. 3. The female client diagnosed with anorexia who reports she does not think she can stand to eat today. 4. The male client diagnosed with Parkinson's disease who reports his hands are shaking more than yesterday

2

The psychiatric nurse is working in an outpatient mental health clinic. Which client should the nurse intervene with first? 1. The client who had a baby 2 months ago and who is sitting alone and looks dejected. 2. The client whose wife just died and who wants to go to heaven to be with her. 3. The client whose mother brought her to the clinic because the mother thinks the client is anorexic. 4. The client who is rocking compulsively back and forth in a chair by the window.

2

The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."

2

Which client should the psychiatric clinic nurse assess first? 1. The client with long-term alcoholism who wants to stop drinking. 2. The client who is a cocaine abuser who is having chest discomfort. 3. The client with obsessive-compulsive disorder who won't quit washing his hands. 4. The client who thinks she was given "the date rape drug" and was raped last night.

2

Which data indicates therapy has been effective for the client diagnosed with bipolar disorder? 1. The client only has four episodes of mania in 6 months. 2. The client goes to work every day for 9 months. 3. The client wears a nightgown to the day room for therapy. 4. The client has had three motor vehicle accidents.

2

Which legal intervention should the nurse implement on the initial visit when admitting a client to the home healthcare agency? 1. Discuss the professional boundary-crossing policy with the client. 2. Provide the client with a copy of the NAHC Bill of Rights. 3. Tell the client how many visits the client will have while on service. 4. Explain that the client must be homebound to be eligible for home healthcare.

2

Which nursing intervention is priority for the client diagnosed with anorexia who is admitted to an inpatient psychiatric unit? 1. Obtain the client's weight. 2. Assess the client's laboratory values. 3. Discuss family issues and health concerns. 4. Teach the client about selective serotonin reuptake inhibitors.

2

Which statement is an example of community-oriented, population-focused nursing? 1. The nurse cares for an older adult client who had a kidney transplant and who lives in the community. 2. The nurse develops an educational program for the type 2 diabetics in the community. 3. The nurse refers a client with Cushing's syndrome to the registered dietician. 4. The nurse provides the client chronic renal disease with pamphlets.

2

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit? 1. Escort the client to the smoking area outside. 2. Obtain vital signs on a newly admitted client. 3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.

2

Which task would be most appropriate for the psychiatric nurse to delegate to the mental health worker (MHW)? 1. Request the MHW to take the client with lithium toxicity to the emergency room. 2. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal. 3. Encourage the MHW to teach the client how to express his or her anger in a positive way. 4. Ask the MHW to sit with the client while the client talks to his mother on the telephone.

2

The client diagnosed with Alzheimer's disease is on a special unit for clients with cognitive disorders. Which assessment data would warrant immediate intervention by the psychiatric nurse? 1. The client does not know his or her name, date, or place. 2. The client is unable to dress himself or herself without assistance. 3. The client is difficult to arouse from sleep. 4. The client needs assistance when eating a meal.

3

The outpatient clinic psychiatric nurse is preparing to assist the healthcare provider to perform electroconvulsive therapy. Rank in order of performance the nursing interventions to be implemented. 1. Attach the electrodes to the client. 2. Check the client's name and date of birth against the chart/orders. 3. Start an intravenous line and run at a keep open rate. 4. Determine that the client has not eaten or had any liquids since midnight. 5. Notify the healthcare provider to begin the procedure.

2, 4, 3, 1, 5

The charge nurse of the psychiatric unit is making assignments. Which clients should be assigned to the medical-surgical nurse who is working in the psychiatric unit for the day? Select all that apply. 1. The client diagnosed with depression who has attempted suicide four times and now is refusing to go to therapy. 2. The client diagnosed with bipolar disease who has diabetes and requires blood glucose monitoring. 3. The female client diagnosed with dissociative identity disorder (DID) who is complaining that she is being falsely imprisoned. 4. The client diagnosed with schizophrenia who is blocking the screen of the television and refuses to move so other clients can watch the television. 5. The client diagnosed with major depression who started taking anti-depressant medication 2 days ago and who wants to remain in bed.

2, 5

. The nurse in the burn unit is preparing to perform a wound dressing change at the bedside. Which interventions should the nurse implement? Rank in order of priority. 1. Obtain the needed supplies for the procedure. 2. Explain the procedure to the client. 3. Remove the old dressing with non-sterile gloves. 4. Medicate the client with narcotic analgesics. 5. Assess the client's burned area

2,4,1,3,5

The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit. 1. Extinguish. 2. Rescue. 3. Confine. 4. Alert.

2,4,3,1

The client tells the nurse, "I am having surgery on my right knee." However, the operative permit is for surgery on the left knee. Which action should the nurse implement first? 1. Notify the operating room team. 2. Initiate the time-out procedure. 3. Clarify the correct extremity with the client. 4. Call the surgeon to discuss the discrepancy

2. According to the Joint Commission, the first intervention is to call a time-out, which stops the surgery until clarification is obtained

A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement? 1. Request all family members to leave the hospital as soon as possible. 2. Instruct the staff to plug critical electrical equipment into the red outlets. 3. Have the unlicensed assistive personnel (UAP) place a portable flashlight on each bedside table. 4. Contact the maintenance department to determine how long the electricity will be out.

2. During an electrical failure, the red outlets in the hospital run on the backup

. The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first? 1. Discuss the infections with the chief nursing officer. 2. Contact the infection control nurse to discuss the problem. 3. Assume the employee health nurse is monitoring the situation. 4. Volunteer to be on an ad hoc committee to research the infection rate.

2. Possibly increasing infection rates among clients with PICCs falls within the infection control nurse's scope of practice, and the infection control nursing staff will have data from all units in the hospital.

The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments? 1. The RN will perform the shift assessments. 2. The LPN should administer all IVP medications. 3. The UAP will complete all a.m. care. 4. The RN will monitor laboratory values

2. The LPN may be allowed administer some IVP medications in some facilities, but the word "all" makes this an inappropriate assignment. Many IVP medications are considered high risk, and only RNs should administer such IVP medications.

The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? 1. Reinsert the nasogastric tube for the client who has pulled it out. 2. Complete the preoperative checklist for the client scheduled for surgery. 3. Instruct the client who is being discharged home about colostomy care. 4. Change the client's surgical dressing that has a 20 cm area of drainage.

2. The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client's safety.

The nurse in an assisted living facility notes that the male client has several new bruises on both of his arms and hands. Which intervention should the nurse implement first? 1. File an elder abuse report with the Department of Human Services. 2. Ask the client whether he has fallen and hurt himself during the night. 3. Check the medication administration record (MAR) to determine which medications the client is receiving. 4. Notify the client's family of the bruises so they are not surprised on their visit.

2. The nurse should ask the client whether there is a reason for the bruises that the nurse should be aware of. This is the first intervention and can be done while the nurse is currently with the client.

The 65-year-old client is being discharged from the hospital following major abdominal surgery and is unable to drive. Which referral should the nurse make to ensure continuity of care? 1. A church that can provide transportation. 2. A home health agency. 3. An outpatient clinic. 4. The healthcare provider's office

2. The nurse should refer the client to a home health agency for follow-up care. The nurse will go to the client's home to assess the client and perform dressing changes. The home health agency will also assess the client and the client's home for further needs.

The HCP is angry and yelling in the nurse's station because the client's laboratory data are not available. Which action should the charge nurse implement first? 1. Contact the laboratory for the client's results. 2. Ask the HCP to step into the nurse's office. 3. Tell the HCP to discuss the issue with the laboratory. 4. Report the HCP's behavior to the chief nursing officer.

2. This is the charge nurse's first action because it will diffuse the HCP's anger. Inappropriate behavior at the nurse's station should not occur in an area where visitors, clients, or staff will observe the behavior.

. The client diagnosed with bipolar disorder and who is prescribed lithium, an antimania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first? 1. Have the laboratory draw a STAT serum lithium level. 2. Evaluate what behavior prompted the psychiatric admission. 3. Assess and treat the client's physiological needs. 4. Administer a STAT dose of lithium to the client.

3

. The client on the psychiatric unit tells the nurse, "I am so bored. I hate just sitting on the unit doing nothing." Which intervention should the nurse implement? 1. Explain that with time the client will be able to go to the activity area. 2. Allow the client to vent feelings of being bored on the unit. 3. Notify the psychiatric recreational therapist about the client's concerns. 4. Tell the client that there is nothing that can be done about being bored.

3

A major disaster has been called, and the charge nurse on a medical unit must recom- mend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? 1. The client diagnosed with chronic angina pectoris who has been on new medication for 2 days. 2. The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days. 3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection. 4. The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH, 7.34; PCO2, 55; HCO3, 28; PaO2, 89.

3

A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying and disheveled, and has bruises on her face. Which action should the triage nurse implement first? 1. Ask the client whether she wants the police department notified. 2. Notify a Sexual Assault Nurse Examiner (SANE) to see the client. 3. Request an ED nurse to take the client to a room and assess for injuries. 4. Assist the client to complete the emergency department admission form.

3

The charge nurse must notify a staff member to stay home because of low census. The unit currently has 35 clients who all have at least one IV and multiple IV medications. The unit is staffed with two RNs, three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which nurse should be notified to stay home? 1. The least experienced RN. 2. The most experienced LPN. 3. The UAP who asked to be requested off. 4. The UAP who was hired 4 weeks ago.

3

The charge nurse responds to an emergency situation on the psychiatric unit in which the male client is angry, yelling, and attempting to hit other clients and the staff. Which interventions should the nurse implement? Select all that apply. 1. Notify the operator to initiate a call for emergency responders to assist. 2. Tell the client to sit down and be quiet or he will lose privileges. 3. Have the mental health worker escort the other clients to their rooms. 4. Make sure that the staff speaks loudly and directly to the client. 5. Request the unit secretary to stand by the locked doors to allow emergency responders on the unit.

3

The client diagnosed with a panic attack disorder in the busy day room of a psychiatric unit becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. Which intervention should the nurse implement first? 1. Administer the benzodiazepine alprazolam (Xanax). 2. Discuss what caused the client to have a panic attack. 3. Escort the client from the day room to a quiet area. 4. Instruct the unlicensed assistive personnel (UAP) to take the client's vital signs.

3

The client diagnosed with bipolar disorder is admitted to the psychiatric unit in an acute manic state. The nurse needs to complete the admission assessment, but the client is restless, very energetic, and agitated. Which intervention should the nurse implement? 1. In a very firm voice, ask the client to sit down. 2. Administer lithium (Eskalith), an antimania medication. 3. Ask questions while walking and pacing with the client. 4. Do not complete the admission assessment at this time.

3

The client diagnosed with hypochondriasis is angry and yells at the psychiatric clinic nurse, "No one believes I am sick! Not my family, not my doctor, and not you." Which statement is the nurse's best response? 1. "Have you discussed your feelings with your family?" 2. "I am sure your doctor believes you are sick." 3. "I can see you are upset. Sit down and let's talk." 4. "We cannot find any physiological reason for your illness."

3

The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement first? 1. Document the client's behavior in the nurse's notes. 2. Instruct the MHWs to clean up the day room area. 3. Obtain a restraint/seclusion order from the HCP. 4. Ensure that none of the other clients were injured.

3

The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first? 1. Increase the client's intravenous rate. 2. Assess the client's vital signs. 3. Apply a tourniquet above the amputation. 4. Notify the client's healthcare provider.

3

The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. Which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager? 1. The nurse provides the client with phone numbers to call if needing assistance. 2. The nurse makes the client a follow-up appointment in the psychiatric clinic. 3. The nurse gives the client a prescription for a 1-month supply of antidepressants. 4. The nurse tells the client not to take any over-the-counter medications.

3

The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first? 1. Discuss the disaster situation with the media. 2. Write the client's name clearly in the disaster log. 3. Place disaster tags securely on the victims. 4. Identify an area for family members to wait

3

The head nurse in a psychiatric unit in the county emergency department is assigning clients to the staff nurses. Which client should be assigned to the most experienced nurse? 1. The client who is crying and upset because she was raped. 2. The client diagnosed with bipolar disorder who is agitated. 3. The client who was found wandering the streets in a daze. 4. The client diagnosed with schizophrenia who is hallucinating.

3

The home health (HH) nurse along with an HH aide is caring for a client who is3 weeks postoperative for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide? 1. Instruct the HH aide to palpate the right pedal pulse. 2. Ask the HH aide to change the right hip dressing. 3. Tell the HH aide to elevate the right leg on two pillows. 4. Request the HH aide to mop the client's bedroom floor.

3

The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? 1. It guarantees that unions will not be able to come into the hospital. 2. It makes the manager responsible for sharing information with the staff. 3. It involves staff nurses in the decision-making process of the unit. 4. It is a system used to represent the nurses in labor disputes.

3

The nurse is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse? 1. The 10-year-old child diagnosed with oppositional defiant disorder who refuses to follow the directions of the mental health worker (MHW). 2. The 5-year-old child diagnosed with pervasive developmental disorder who refuses to talk to the nurse and will not make eye contact. 3. The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room. 4. The 8-year-old mentally retarded child who is sitting on the playground and eating dirt and sand.

3

The nurse is working in an outpatient psychiatric clinic. The male client tells the nurse, "I am going to kill my wife if she files for divorce. I know I can't live without her." Which action should the nurse implement? 1. Take no action because this is confidential information. 2. Document the statement in the client's nurse's notes. 3. Inform the client's psychiatric healthcare provider (HCP) of the comment. 4. Encourage the client to talk to his wife about the divorce.

3

The nurse on the psychiatric unit observes one client shove another client. Which intervention should the nurse implement first? 1. Discuss the aggressive behavior with the client. 2. Document the occurrence in the client's chart. 3. Approach the client with another staff member. 4. Instruct the client to go to the unit's quiet room.

3

The nurse on the substance abuse unit is administering medications. For which client would the nurse question administering the medication? 1. The client admitted for alcohol detoxification who is receiving lorazepam (Ativan) and has an apical pulse of 110. 2. The client admitted for heroin addiction who is receiving methadone (Methadose) and has a respiratory rate of 22. 3. The client admitted for opioid withdrawal who is receiving clonidine (Catapres) and has a blood pressure (BP) of 88/60. 4. The client diagnosed with Wernicke-Korsakoff syndrome receiving intravenous thiamine (vitamin B1) who has an oral temperature of 96.8°F.

3

The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? 1. Administer a pain medication 30 minutes before therapy. 2. Give the client a washcloth to wash his or her face before walking. 3. Check to make sure the client has been offered the use of the bathroom. 4. Find a walker that is the correct height for the client to use.

3

The psychiatric charge nurse is making shift assignments for the admission unit. The staff includes one registered nurse (RN), two licensed practical nurses (LPNs), four mental health workers (MHWs), and a unit secretary. Which task would be most appropriate to assign to the LPNs? 1. Update the clients' individualized care plans. 2. Stay in the lobby area and watch the clients. 3. Administer routine medications to the clients. 4. Transcribe the admission orders for a client.

3

The psychiatric nurse is caring for clients on a closed unit. Which client would warrant immediate intervention by the nurse? 1. The client who refuses to attend the anger management class. 2. The client who is requesting to go outside to smoke a cigarette. 3. The client who is nauseated and has vomited twice. 4. The client who has her menses and has abdominal cramping.

3

The psychiatric nurse overhears a mental health worker (MHW) telling a client diagnosed with schizophrenia, "You cannot use the phone while you are here on the unit." Which action should the psychiatric nurse take? 1. Praise the MHW for providing correct information to the client. 2. Tell the MHW this is not correct information in front of the client. 3. Explain to the MHW that the client does not lose any rights. 4. Discuss this situation at the weekly multidisciplinary team meeting.

3

The psychiatric unit staff is upset about the new female charge nurse who just sits in her office all day. One of the staff members informs the clinical manager about the situation. Which statement by the clinical manager indicates a laissez-faire leadership style? 1. "I will schedule a meeting to discuss the concerns of the charge nurse." 2. "I hired the new charge nurse and she is doing what I told her to do." 3. "You and the staff really should take care of this situation on your own." 4. "I will talk to the charge nurse about your concerns and get back to you."

3

Which action by the nurse is a violation of the Joint Commission's Patient Safety Goals? 1. The surgery nurse calls a time-out when a discrepancy is noted on the surgical permit. 2. The unit nurse asks the client for his or her date of birth before administering medications. 3. The nurse educator gives the orientee the answers to the quiz covering the IV pumps. 4. The admitting nurse initiates the facility's fall prevention program on an older adult client.

3

Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis? 1. The client's serum creatinine level is 2.4 mg/dL. 2. The client's abdomen is soft to touch and nontender. 3. The dialysate being removed from the abdomen is cloudy. 4. The dialysate instilled was 1,500 mL and removed was 2,100 mL.

3

Which client should the psychiatric charge nurse assign to the nurse from the surgical unit who was assigned to the psychiatric unit for the shift? 1. The client diagnosed with schizophrenia who is hallucinating and delusional. 2. The client with bipolar disorder who is manic and aggressive toward staff and clients. 3. The client who is diagnosed with chronic depression and will not talk to anyone. 4. The client with schizophrenia and an Axis 2 antisocial personality.

3

Which situation requires priority intervention on an inpatient psychiatric unit? 1. A client is threatening to throw the television at another client. 2. A male client wants to use the phone to call his spouse. 3. A client sitting in a chair is delusional and hallucinating. 4. A client has refused to eat anything for the last 2 days.

3

Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report? 1. The client diagnosed with paranoid schizophrenia who is delusional. 2. The p.m. shift licensed practical nurse (LPN) called in to say he or she would not be able to work today. 3. The male mental health worker (MHW) reports losing his unit key and identification card. 4. The unit secretary has HCP's orders that need to be co-signed.

3

Which statement by the mental health worker (MHW) warrants intervention by the psychiatric nurse? 1. "I assisted the client with dressing and hygiene this morning." 2. "I am going to the team meeting for the next hour." 3. "I gave the client with heart burn some Maalox." 4. "I am going to play cards with some clients in the day room."

3

. Which interventions should the inpatient psychiatric nurse implement for the client experiencing sleepwalking? Select all that apply. 1. Encourage the client to exercise prior to going to bed. 2. Place the client on elopement precautions. 3. Instruct to client to drink decaffeinated beverages. 4. Place an alarm on the bed activated when client gets up. 5. Tell the MHW to be on a 1-to-1 watch during the night.

3, 4

The nurse is discussing the grieving process with the client. Which stages are included in Kübler-Ross's stages of grief? Rank in the correct order. 1. Acceptance. 2. Bargaining. 3. Denial. 4. Anger. 5. Depression

3, 4, 2, 5, 1

The critical care unit is having problems with staff members clocking in late and clocking out early from the shift. Which statement by the charge nurse indicates he has a democratic leadership style? 1. "You cannot clock out 1 minute before your shift is complete." 2. "As long as your work is done you can clock out any time you want." 3. "We are going to have a meeting to discuss the clocking in procedure." 4. "The clinical manager will take care of anyone who clocks out early."

3. A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open and communication flows both ways, and this includes having meetings to discuss concerns.

The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit? 1. Send the unlicensed assistive personnel (UAP) who has worked on the surgical unit for 5 years. 2. Send the RN who has worked in the hospital for 8 years in a variety of areas. 3. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit. 4. Send the new graduate nurse who is orienting to the surgical unit

3. The LPN would be the most appropriate staff to send to the medical unit because the LPN has experience on the unit. His or her expertise is also not required to perform custodial care.

The nurse in the critical care unit of a medical center answers the phone and the person says, "There is a bomb in the hospital kitchen." Which action should the nurse take? 1. Notify the kitchen that there is a bomb. 2. Call the operator to trace the phone call. 3. Notify the hospital security department. 4. Call the local police department.

3. The chain of command in a hospital is to notify the security department, and they will institute the hospital procedure for the bomb threat.

The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client? 1. To a home healthcare agency. 2. To a senior citizen center. 3. To a rehabilitation facility. 4. To an outpatient physical therapist.

3. The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client's recovery.

The newly admitted client in a long-term care facility stays in the room and refuses to participate in client activities. Which statement is a priority for the nurse to discuss with the client? 1. "You have to get out of this room or you will never make friends here at the home." 2. "It is not so bad living here; you are lucky that we care about what happens to you." 3. "You seem sad; would you like to talk about how you are feeling about being here?" 4. "The activities director can arrange for someone to come and visit you in your room."

3. This client is exhibiting symptoms of depression. Therapeutic conversation is implemented to help the client vent feelings. This statement acknowledg

Which client should the charge nurse of a long-term care facility see first after receiving shift report? 1. The client who is unhappy about being placed in a long-term care facility. 2. The client who wants to have the HCP to order a nightly glass of wine. 3. The client who is upset because the call light was not answered for 30 minutes. 4. The client whose son is being discharged from the hospital after heart surgery.

3. This client may or may not have a valid complaint. The nurse should investigate whether or not the complaint is true. Failure to answer a call light can result in the client's attempting to ambulate without assistance and could be a safety issue. The nurse should speak with this client first.

The nurse is discussing the grieving process with the client. Which stages are included in Kübler-Ross's stages of grief? Rank in the correct order. 1. Acceptance. 2. Bargaining. 3. Denial. 4. Anger. 5. Depression.

34251

. The psychiatric nurse assigned the mental health worker (MHW) to stay with a client 1-to-1 due to high risk for suicide. Which behavior by the MHW warrants intervention by the nurse? 1. The MHW stays with the client while in the bathroom. 2. The MHW provides the client with plastic utensils for breakfast. 3. The MHW stays outside the room during the client's group therapy. 4. The MHW watches the client walking outside from the porch area.

4

At 0830, the day shift nurse is preparing to administer medications to the client. Which action should the nurse take first? 1. Check the client's armband against the medication administration record (MAR). 2. Assess the client's IV site for redness and patency. 3. Ask for the client's date of birth. 4. Determine the client's last K_ level.

4

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction (MI) who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

4

The client enters a mental health clinic with a gun and is threatening to kill the nurse who told his wife to leave him. Which action should the nurse implement first? 1. Instruct a staff member to call the local police department. 2. Evacuate the clients and staff to a safe and secure place. 3. Encourage the client to talk about his feelings of anger. 4. Calmly and firmly ask the man to put the gun down on the floor.

4

The client in the operating room states, "I don't think I will have this surgery after all." Which intervention should the nurse implement first? 1. Have the surgeon speak with the client. 2. Ask the client to discuss the concerns. 3. Continue to prep the client for surgery. 4. Immediately stop the surgical procedure.

4

The client in the psychiatric setting tells the nurse, "There were so many people at the team meeting; I am not sure what the psychiatric social worker is supposed to do for me." Which statement is the psychiatric nurse's best response? 1. "The social worker evaluates the effectiveness of the client's medication." 2. "This person provides activities that promote constructive use of leisure time." 3. "The social worker will assist you in keeping your job or help you find a new one." 4. "This person works with your family and community and makes referrals if needed."

4

The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first? 1. Document the findings in the client's chart. 2. Elevate the client's right hand. 3. Assess the radial pulse with the Doppler. 4. Notify the client's healthcare provider

4

The clinic nurse is reviewing the laboratory data of clients seen in the clinic the previous day. Which client requires immediate intervention by the nurse? 1. The client whose white blood cell (WBC) count is 9.5 mm3. 2. The client whose cholesterol level is 230 mg/dL. 3. The client whose calcium level is 10.4 mg/dL. 4. The client whose International Normalized Ratio (INR) is 3.8.

4

The psychiatric nurse has taken 15 minutes extra for the lunch break two times in the last week. Which action should the female clinical manager implement? 1. Take no action and continue to watch the nurse's behavior. 2. Document the behavior in writing and place in the nurse's file. 3. Tell the nurse to check in and out with her when taking lunch. 4. Talk to the nurse informally about taking 45 minutes for lunch.

4

The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing? 1. The client diagnosed with AIDS who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled. 3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

4

The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement? 1. Discuss the situation with the client's family. 2. Refer the client to the HH occupational therapist. 3. Request the HH aide to cook all the client's meals. 4. Contact the community's Meals on Wheels.

4

The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement? 1. Bathe the client who is incontinent of urine. 2. Document the amount of food the client eats. 3. Conduct the afternoon bingo game in the lobby. 4. Perform routine dressing changes on assigned clients.

4

The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement first? 1. Ask the wife for her opinion of how the visit went. 2. Determine whether the client took his medication. 3. Ask the client for his opinion of how the visit went. 4. Check the client for sharps or dangerous objects.

4

The male client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take first? 1. Obtain a restraint order from the HCP. 2. Escort the other clients from the day room. 3. Administer an intramuscular (IM) antipsychotic medication. 4. Approach the client calmly along with two mental health workers (MHWs).

4

The mental health worker (MHW) reports to the psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement? 1. Tell the MHW to tell the clients not to kiss each other again. 2. Discuss the inappropriate behavior at the weekly team meeting. 3. Transfer one of the clients to another psychiatric unit. 4. Talk to the clients about kissing each other in the lobby area

4

The new nurse on the psychiatric unit tells the charge nurse, "I don't like how the shift report is given." Which statement is the charge nurse's best response? 1. "Since you're new I think you should try it our way before making any comments." 2. "We have been doing the shift report this way since I started working here more than 5 years ago." 3. "Have you discussed your concerns about the shift report with the other nurses?" 4. "I would be happy to listen to any ideas you have on how to give the shift report."

4

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP? 1. Sit with the 6-year-old client while the parent goes outside to smoke. 2. Stay with the 4-year-old client during scheduled play therapy sessions. 3. Position the 2-year-old client for the postural drainage therapy. 4. Weigh the diaper of the 6-month-old client who is on intake and output (I&O).

4

The nurse answers the client's phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement? 1. Ask the caller who is asking for Mr. Jones. 2. Tell the caller Mr. Jones cannot have phone calls. 3. Request the caller to give the access code for information. 4. Find Mr. Jones and tell him he has a phone call.

4

The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first? 1. The client diagnosed with agoraphobia who is calling to cancel the clinic appointment. 2. The client diagnosed with a somatoform disorder who has numbness in both legs. 3. The client diagnosed with hypochondriasis who is afraid she may have breast cancer. 4. The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.

4

The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client's condition. Which information should the nurse discuss with the volunteer? 1. Determine how well she knows the client before talking with the volunteer. 2. Tell the volunteer the client's condition in layperson's terms. 3. Ask the client if it is all right to talk with the volunteer. 4. Explain that client information is on a need-to-know basis only.

4

Which behavior by the mental health worker (MHW) is an example of assault requiring immediate intervention by the psychiatric nurse? 1. The MHW injures a client who is forcibly being put in the "quiet" room. 2. The MHW refuses to let the client come into the day room until putting on socks. 3. The MHW escorts the client to the anger management class in another building. 4. The MHW threatened to forcibly remove the client who is refusing to get out of the bed.

4

Which client should the psychiatric nurse working in a mental health clinic refer to the psychiatric social worker? 1. The client who was raped and wants help to be able to get on with her life. 2. The client who is scheduled for the first electroconvulsive therapy treatment. 3. The client who reports having difficulty going to work every day. 4. The client who is unable to buy the prescribed antipsychotic medications

4

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit. 2. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles. 3. The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain. 4. The client with Crohn's disease who has right lower abdominal pain and has diarrhea.

4

Which client would most benefit from acupuncture, a traditional Chinese medicine considered complementary alternative medicine? 1. The client who is diagnosed with deep vein thrombosis. 2. The client who is diagnosed with Alzheimer's disease. 3. The client diagnosed with reactive airway disease. 4. The client diagnosed with osteoarthritis.

4

Which task would be inappropriate for the psychiatric charge nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to escort the client to the multidisciplinary team meeting. 2. Ask the MHW to stay in the day room and watch the clients. 3. Tell the MHW to take care of the client on a 1-to-1 suicide watch. 4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.

4

The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, "I don't want to go to the nursing home but my son says I have to." Which response would be most appropriate by the nurse? 1. "Let me call a meeting of the healthcare team and your son." 2. "Has the social worker talked to you about this already?" 3. "Why are you so upset about going to the nursing home?" 4. "I can see you are upset. Would you like to talk about it?"

4. According to the NCLEX-RN® test plan, advocacy is part of Management of Care under Safe and Effective Care Environment client needs. Therapeutic communication involves being an advocate in this situation, because sometimes the nurse cannot prevent a perceived "bad" situation from occurring

The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first? 1. The client who is 4 hours postoperative for abdominal surgery who is complaining of abdominal pain and has hypoactive bowel sounds. 2. The client who is 1 day postoperative for total hip replacement (THR) who has voided 550 mL of clear amber urine in the last 8 hours. 3. The client who is 8 hours postoperative for open cholecystectomy who has a T-tube draining green bile. 4. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot.

4. The client is exhibiting signs of compromised circulation; therefore, the nurse should assess this client first. The nurse should assess for the 6 Ps: pain, pulse, paresthesia, paralysis, pallor, and polar (cold).

The male client in a long-term care facility complains that the staff does not listen to his complaints unless a family member also complains. Which action should the director of nurses implement? 1. Call a staff meeting and tell the staff to listen to the resident when he talks to them. 2. Determine who neglected to listen to the resident and place the staff member on leave. 3. Ignore the situation because a resident in long-term care cannot determine his needs. 4. Talk with the resident about his concerns and then initiate a plan of action

4. The director of nurses should discuss the resident's complaints with the resident and then determine a plan of action to remedy the situation.

The admitting nurse is subpoenaed to give testimony in a case in which the client fell from the bed and fractured the left hip. The nurse initiated fall precautions on admission but was not on duty when the client fell. Which issue should the nurse be prepared to testify about the incident? 1. What preceded the client's fall from the bed. 2. The extent of injuries the client sustained. 3. The client's mental status before the incident. 4. The facility's policy covering falls prevention.

4. The nurse initiated a policy that is designed to prevent falls from occurring

The head nurse is completing the yearly performance evaluation on a nurse. Which data regarding the nurse's performance should be included in the evaluation? 1. The number of times the nurse has been tardy. 2. The attitude of the nurse at the client's bedside. 3. The thank you notes the nurse received from clients. 4. The chart audits of the clients for whom the nurse cared.

4. The nurse's ability to document client care directly correlates with the nurse's performance; therefore, these data should be included in the yearly evaluation

The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. 1. Teach the parent about weighing diapers to determine output status. 2. Show the parent the call light and explain safety regimens. 3. Assess the toddler's tissue turgor. 4. Place the appropriate size diapers in the room. 5. Take the toddler's vital signs.

5, 3, 2, 4, 1

The nurse is caring for clients in the psychiatric unit. Which task would be most appropriate for the nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to walk with the client who is agitated and anxious. 2. Ask the MHW to clean up the floor where the client has urinated. 3. Tell the MHW to phone the HCP to obtain a PRN medication order. 4. Request the MHW to explain seizure precautions to another staff member.

Instruct the MHW to walk with the client who is agitated and anxious.

The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement first? 1. Document the client's behavior in the nurse's notes. 2. Instruct the MHWs to clean up the day room area. 3. Obtain a restraint/seclusion order from the HCP. 4. Ensure that none of the other clients were injured.

Obtain a restraint/seclusion order from the HCP.

The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? 1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. 2. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau's sign.

1

The client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight (IBW) for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement? 1. Notify the psychiatrist to request a court order to feed the client. 2. Take no action because the client has the right to refuse treatment. 3. Discharge the client because she is not complying with the treatment. 4. Physically restrain the client and insert a nasogastric tube for feeding.

1

The client in the psychiatric unit tells the nurse, "Someone just put a bomb under the couch in the lobby." Which action should the nurse implement first? 1. Look under the couch for a bomb. 2. Implement the bomb scare protocol. 3. Have the staff evacuate the unit. 4. Tell the client there is no bomb.

1

The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? 1. Instruct her to assist the client with a shower. 2. Ask her to prepare the breakfast meal for the client. 3. Request her to take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

1

The client diagnosed with paranoid schizophrenia is imminently aggressive and is dangerous to himself, the other clients, and the psychiatric staff members. The client is placed in a seclusion room. Which interventions should the psychiatric nurse implement? Select all that apply. 1. Assess the client every 2 hours for side effects of medication. 2. Tell the client what behavior will prompt the release from seclusion. 3. Do not notify the client's family of the initiation of seclusion. 4. Explain that the client will be in the seclusion room for 24 hours. 5. Instruct the MHW to check the client every 10 to 15 minutes.

1 2 5

The client with long-term alcoholism asks the nurse, "How does Alcoholics Anonymous help me quit drinking?" Which statements are the nurse's best responses? Select all that apply. 1. "AA has sponsors whom you can contact if you want to take a drink." 2. "AA discusses medications used to help prevent drinking alcohol." 3. "AA is a support group of alcoholics who have successfully quit drinking." 4. "AA helps you realize the power you have over your addiction to alcohol." 5. "AA has professional guest speakers to address addictive personalities."

1 3

During an interview, the female client tells the psychiatric nurse in a mental health clinic, "Sometimes I feel like life is not worth living. I am going to kill myself." Which interventions should the nurse implement? Select all that apply. 1. Make a no-suicide contract with the client. 2. Place the client on a 1-to-1 supervision. 3. Ask the client whether she has a plan. 4. Commit the client to the psychiatric unit. 5. Assess the client's support system.

1 3 5

The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? 1. Ask the charge nurse to teach all the other UAPs. 2. Encourage the nurse to continue to work with the UAP. 3. Tell the charge nurse to discuss this in a private area. 4. Give the UAP a better explanation of the procedure.

2

The male client in the psychiatric unit asks the MHW to mail a letter to his family for him. Which action would warrant intervention by the psychiatric nurse? 1. The MHW tells the client to place the letter in the mailbox. 2. The MHW informs the client he cannot send mail to his family. 3. The MHW takes the letter and places it in the unit mailbox. 4. The MHW reports the client mailed a letter at the team meeting.

2

The nurse is caring for clients in an outpatient psychiatric clinic. Which client would the nurse discuss with the healthcare provider? 1. The client diagnosed with bipolar disorder who is receiving carbamazepine (Tegretol), an anticonvulsant. 2. The client diagnosed with schizophrenia who reports taking the antacid Maalox daily for heartburn. 3. The client diagnosed with major depression who is receiving isoniazid (INH), an antituberculosis medication. 4. The client diagnosed with anorexia nervosa who is receiving amitriptyline (Elavil), a tricyclic antidepressant.

2

The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

2

The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? 1. The nurse who has the most vacation time. 2. The nurse who requested to be off. 3. The nurse who has the least experience on the unit. 4. The nurse who has called in sick the previous 2 days.

2

The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? 1. The UAP is not at risk for contracting an illness. 2. The UAP should wear a mask, gown, and gloves. 3. The UAP may skip performing postmortem care. 4. Ask whether the UAP is pregnant before she enters the client's room.

2

Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

2

The charge nurse of the psychiatric unit is making assignments. Which clients should be assigned to the medical-surgical nurse who is working in the psychiatric unit for the day? Select all that apply. 1. The client diagnosed with depression who has attempted suicide four times and now is refusing to go to therapy. 2. The client diagnosed with bipolar disease who has diabetes and requires blood glucose monitoring. 3. The female client diagnosed with dissociative identity disorder (DID) who is complaining that she is being falsely imprisoned. 4. The client diagnosed with schizophrenia who is blocking the screen of the television and refuses to move so other clients can watch the television. 5. The client diagnosed with major depression who started taking anti-depressant medication 2 days ago and who wants to remain in bed.

2 5

The outpatient clinic psychiatric nurse is preparing to assist the healthcare provider to perform electroconvulsive therapy. Rank in order of performance the nursing interventions to be implemented. 1. Attach the electrodes to the client. 2. Check the client's name and date of birth against the chart/orders. 3. Start an intravenous line and run at a keep open rate. 4. Determine that the client has not eaten or had any liquids since midnight. 5. Notify the healthcare provider to begin the procedure.

24315

The client diagnosed with Alzheimer's disease is on a special unit for clients with cognitive disorders. Which assessment data would warrant immediate intervention by the psychiatric nurse? 1. The client does not know his or her name, date, or place. 2. The client is unable to dress himself or herself without assistance. 3. The client is difficult to arouse from sleep. 4. The client needs assistance when eating a meal.

3

The client diagnosed with bipolar disorder and who is prescribed lithium, an antimania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first? 1. Have the laboratory draw a STAT serum lithium level. 2. Evaluate what behavior prompted the psychiatric admission. 3. Assess and treat the client's physiological needs. 4. Administer a STAT dose of lithium to the client.

3

The client on the psychiatric unit tells the nurse, "I am so bored. I hate just sitting on the unit doing nothing." Which intervention should the nurse implement? 1. Explain that with time the client will be able to go to the activity area. 2. Allow the client to vent feelings of being bored on the unit. 3. Notify the psychiatric recreational therapist about the client's concerns. 4. Tell the client that there is nothing that can be done about being bored.

3

The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? 1. Tell the HH aide to allow the client to stay in bed until the pain goes away. 2. Instruct the HH aide to get the client up to a chair and give her a bath. 3. Explain to the HH aide the client should get up and take a warm shower. 4. Arrange an appointment for the client to visit her healthcare provider.

3

The head nurse in a psychiatric unit in the county emergency department is assigning clients to the staff nurses. Which client should be assigned to the most experienced nurse? 1. The client who is crying and upset because she was raped. 2. The client diagnosed with bipolar disorder who is agitated. 3. The client who was found wandering the streets in a daze. 4. The client diagnosed with schizophrenia who is hallucinating.

3

The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualified. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

3

The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? 1. Apply a sterile dressing to a Stage IV pressure wound. 2. Check the blood glucose level of a resident who is weak and shaky. 3. Document the amount of food the residents ate after a meal. 4. Teach the residents how to play different types of bingo.

3

Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report? 1. The client diagnosed with paranoid schizophrenia who is delusional. 2. The p.m. shift licensed practical nurse (LPN) called in to say he or she would not be able to work today. 3. The male mental health worker (MHW) reports losing his unit key and identification card. 4. The unit secretary has HCP's orders that need to be co-signed.

3

Which interventions should the inpatient psychiatric nurse implement for the client experiencing sleepwalking? Select all that apply. 1. Encourage the client to exercise prior to going to bed. 2. Place the client on elopement precautions. 3. Instruct to client to drink decaffeinated beverages. 4. Place an alarm on the bed activated when client gets up. 5. Tell the MHW to be on a 1-to-1 watch during the night.

3 4

The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's abdominal dressing for drainage. 3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

3, 4, 5

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

4

The psychiatric nurse has taken 15 minutes extra for the lunch break two times in the last week. Which action should the female clinical manager implement? 1. Take no action and continue to watch the nurse's behavior. 2. Document the behavior in writing and place in the nurse's file. 3. Tell the nurse to check in and out with her when taking lunch. 4. Talk to the nurse informally about taking 45 minutes for lunch.

4

Which client should the psychiatric nurse working in a mental health clinic refer to the psychiatric social worker? 1. The client who was raped and wants help to be able to get on with her life. 2. The client who is scheduled for the first electroconvulsive therapy treatment. 3. The client who reports having difficulty going to work every day. 4. The client who is unable to buy the prescribed antipsychotic medications.

4

The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the nurse the client is really agitated and anxious, and has slurred speech. Which intervention should the nurse implement first? 1. Assess the client for heroin withdrawal. 2. Ask the UAP to take the client's vital signs. 3. Notify the client's healthcare provider. 4. Administer chlordiazepoxide (Librium), an antianxiety medication.

Assess the client for heroin withdrawal.

The mental health worker (MHW) has tried to calm down the client on the psychiatric unit who is angry and attempting to fight with another client. The nurse observes the MHW "taking down" the client to the floor. Which intervention should the nurse implement? 1. Assist the MHW with the "take down" of the client. 2. Call the hospital security to come and assist the MHW. 3. Document the client "take down" in the nurse's notes. 4. Remove the other clients from the day room area.

Assist the MHW with the "take down" of the client

The client diagnosed with schizophrenia is being seen by the psychiatric clinic nurse for the initial visit. Which intervention should the nurse implement first? 1. Develop a trusting nurse/client relationship. 2. Determine the client's knowledge of medication. 3. Assess the client's support systems. 4. Allow the client to vent their feelings.

Develop a trusting nurse/client relationship.

The psychiatric nurse overhears a mental health worker (MHW) telling a client diagnosed with schizophrenia, "You cannot use the phone while you are here on the unit." Which action should the psychiatric nurse take? 1. Praise the MHW for providing correct information to the client. 2. Tell the MHW this is not correct information in front of the client. 3. Explain to the MHW that the client does not lose any rights. 4. Discuss this situation at the weekly multidisciplinary team meeting.

Explain to the MHW that the client does not lose any rights.

Which task would be most appropriate for the psychiatric nurse to delegate to the mental health worker (MHW)? 1. Request the MHW to take the client with lithium toxicity to the emergency room. 2. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal. 3. Encourage the MHW to teach the client how to express his or her anger in a positive way. 4. Ask the MHW to sit with the client while the client talks to his mother on the telephone.

Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal.

The psychiatric nurse assigned the mental health worker (MHW) to stay with a client 1-to-1 due to high risk for suicide. Which behavior by the MHW warrants intervention by the nurse? 1. The MHW stays with the client while in the bathroom. 2. The MHW provides the client with plastic utensils for breakfast. 3. The MHW stays outside the room during the client's group therapy. 4. The MHW watches the client walking outside from the porch area.

The MHW watches the client walking outside from the porch area.

The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first? 1. The female client diagnosed with histrionic personality disorder who needs to talk to the nurse about something very important. 2. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. 3. The male client diagnosed with major depression whose wife called and said he was talking about killing himself. 4. The client diagnosed with bipolar disorder who is manic and has not slept for the last 2 days.

The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother.

A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse's station saying, "I am Joey's father; can you tell me how he is doing?" Which statement is the nurse's best response? 1. "Your son has a fractured jaw and some bruises but he is doing fine." 2. "I am sorry I cannot give you any information about your son." 3. "You should go talk to your wife about your son's condition." 4. "The social worker can discuss your son's condition with you."

"I am sorry I cannot give you any information about your son."

The client diagnosed with hypochondriasis is angry and yells at the psychiatric clinic nurse, "No one believes I am sick! Not my family, not my doctor, and not you." Which statement is the nurse's best response? 1. "Have you discussed your feelings with your family?" 2. "I am sure your doctor believes you are sick." 3. "I can see you are upset. Sit down and let's talk." 4. "We cannot find any physiological reason for your illness."

"I can see you are upset. Sit down and let's talk."

Which statement by the mental health worker (MHW) warrants intervention by the psychiatric nurse? 1. "I assisted the client with dressing and hygiene this morning." 2. "I am going to the team meeting for the next hour." 3. "I gave the client with heart burn some Maalox." 4. "I am going to play cards with some clients in the day room."

"I gave the client with heart burn some Maalox."

The client in the psychiatric setting tells the nurse, "There were so many people at the team meeting; I am not sure what the psychiatric social worker is supposed to do for me." Which statement is the psychiatric nurse's best response? 1. "The social worker evaluates the effectiveness of the client's medication." 2. "This person provides activities that promote constructive use of leisure time." 3. "The social worker will assist you in keeping your job or help you find a new one." 4. "This person works with your family and community and makes referrals if needed."

"This person works with your family and community and makes referrals if needed."

The client diagnosed with a panic attack disorder in the busy day room of a psychiatric unit becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. Which intervention should the nurse implement first? 1. Administer the benzodiazepine alprazolam (Xanax). 2. Discuss what caused the client to have a panic attack. 3. Escort the client from the day room to a quiet area. 4. Instruct the unlicensed assistive personnel (UAP) to take the client's vital signs.

. Escort the client from the day room to a quiet area.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The client who had surgery for an inguinal hernia and who is being prepared for discharge. 2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. 3. The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. 4. The client who has end-stage renal disease and who has had an arteriovenous fistula created.

1

The charge nurse responds to an emergency situation on the psychiatric unit in which the male client is angry, yelling, and attempting to hit other clients and the staff. Which interventions should the nurse implement? Select all that apply. 1. Notify the operator to initiate a call for emergency responders to assist. 2. Tell the client to sit down and be quiet or he will lose privileges. 3. Have the mental health worker escort the other clients to their rooms. 4. Make sure that the staff speaks loudly and directly to the client. 5. Request the unit secretary to stand by the locked doors to allow emergency responders on the unit.

1 3 5

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? 1. The client diagnosed with dementia who is confused and disoriented. 2. The client diagnosed with schizophrenia who is experiencing tardive dyskinesia. 3. The client diagnosed with bipolar disorder who has a lithium level of 2.0 mEq/L. 4. The client diagnosed with chronic alcoholism who is experiencing delirium tremens.

1. The client diagnosed with dementia who is confused and disoriented.

The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

2

The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers?1. No information can be released to the mortuary service. 2. The nurse should tell the funeral home the client's diagnosis. 3. Ask the family for permission to talk with the mortician. 4. Refer the funeral home to the HCP for information.

2

The client on a psychiatric involuntary admission is threatening to run away from the unit. Which intervention should the nurse implement first? 1. Notify the police department of the client's threats. 2. Place the unit on high alert for unauthorized departure. 3. Talk to the client about the threat of running away. 4. Have the client sign out against medical advice (AMA).

2

The client seeing the psychiatric nurse in the mental health clinic tells the nurse, "If I tell you something very important, will you promise not to tell anyone?" Which statement is the nurse's best response? 1. "I promise I will not tell anyone if you don't want me to." 2. "If it affects your care I will have to tell someone who can help." 3. "If you don't want me to tell anyone, then please don't tell me." 4. "Why do you not want me to tell anyone if it is so important?"

2

The mental health worker (MHW) reports that one of the nurses threatened to forcefeed the male client diagnosed with schizophrenia if the client did not eat the meal on the lunch tray. Which action should the charge nurse take first? 1. Tell the MHW that this intervention is part of the client's care plan. 2. Request the nurse to come to the office and discuss the MHW's allegation. 3. Ask the client what happened between him and the nurse during lunch. 4. Ask the MHW to write down the situation to submit to the head nurse.

2

The mother of a client recently diagnosed with schizophrenia says to the nurse, "I was afraid of my son. Will he be all right?" Which response by the psychiatric nurse supports the ethical principal of veracity? 1. "I can see your fear; you are concerned your son will not be all right." 2. "If your son takes medication, the symptoms can be controlled." 3. "Why were you afraid of your son? Did you think he would hurt you?" 4. "Schizophrenia is a mental illness and your son will not be all right."

2

The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

2

The nurse is in the middle/working phase of the nurse/client relationship. Which statement is a task in the orientation phase? 1. Identify the client's strengths and weaknesses. 2. Help the client identify problem-solving techniques. 3. Evaluate the client's experience while in the group. 4. Establish the rules for how the meetings will be conducted.

2

The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? 1. The client diagnosed with flail chest who has just come from the operating room with a right-sided chest tube. 2. The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy. 3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact. 4. The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism

3. Although the client is only 1 day postoperative for a total hip replacement, it is an elective procedure, which indicates that the client was stable prior to the surgery. The incision is also dry and intact. Of the four clients, this client is the most stable and should be transferred to the surgical unit.

The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement? 1. Ask the UAP to take the client's vital signs. 2. Request the UAP to log roll the client to the right side. 3. Complete the neurovascular assessment on the client's legs. 4. Contact the physical therapist to check the client.

3. The nurse should assess the client whenever receiving any information from another member of the healthcare team

The unlicensed assistive personnel (UAP) is changing a full sharps container in the client's room. Which action should the nurse implement? 1. Tell the UAP she cannot change the sharps container. 2. Explain the housekeeping department changes the sharps containers. 3. Praise the UAP for taking the initiative to change the sharps container. 4. Report the behavior to the clinical manager on the unit.

3. The nurse should reward appropriate behavior by the other healthcare members.

The psychiatric charge nurse is making shift assignments for the admission unit. The staff includes one registered nurse (RN), two licensed practical nurses (LPNs), four mental health workers (MHWs), and a unit secretary. Which task would be most appropriate to assign to the LPNs? 1. Update the clients' individualized care plans. 2. Stay in the lobby area and watch the clients. 3. Administer routine medications to the clients. 4. Transcribe the admission orders for a client.

Administer routine medications to the clients

The male client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take first? 1. Obtain a restraint order from the HCP. 2. Escort the other clients from the day room. 3. Administer an intramuscular (IM) antipsychotic medication. 4. Approach the client calmly along with two mental health workers (MHWs).

Approach the client calmly along with two mental health workers (MHWs).

The client diagnosed with bipolar disorder is admitted to the psychiatric unit in an acute manic state. The nurse needs to complete the admission assessment, but the client is restless, very energetic, and agitated. Which intervention should the nurse implement? 1. In a very firm voice, ask the client to sit down. 2. Administer lithium (Eskalith), an antimania medication. 3. Ask questions while walking and pacing with the client. 4. Do not complete the admission assessment at this time.

Ask questions while walking and pacing with the client.

The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement first? 1. Ask the wife for her opinion of how the visit went. 2. Determine whether the client took his medication. 3. Ask the client for his opinion of how the visit went. 4. Check the client for sharps or dangerous objects.

Check the client for sharps or dangerous objects.

The client diagnosed with a somatization disorder is complaining of vomiting, having diarrhea, and having a fever. Which intervention should the nurse implement first? 1. Assess the client's anxiety level on a scale of 1 to 10. 2. Check the client's vital signs. 3. Discuss problem-solving techniques. 4. Notify the client's healthcare provider.

Check the client's vital signs.

The psychiatric nurse is reviewing client lab values. Which of the following data requires immediate intervention by the nurse?

Client C

A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying and disheveled, and has bruises on her face. Which action should the triage nurse implement first? 1. Ask the client whether she wants the police department notified. 2. Notify a Sexual Assault Nurse Examiner (SANE) to see the client. 3. Request an ED nurse to take the client to a room and assess for injuries. 4. Assist the client to complete the emergency department admission form.

Request an ED nurse to take the client to a room and assess for injuries.

24. The mental health worker (MHW) reports to the psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement? 1. Tell the MHW to tell the clients not to kiss each other again. 2. Discuss the inappropriate behavior at the weekly team meeting. 3. Transfer one of the clients to another psychiatric unit. 4. Talk to the clients about kissing each other in the lobby area.

Talk to the clients about kissing each other in the lobby area.

The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first? 1. Tell the man the client needs to go to the x-ray department. 2. Notify hospital security and have the man removed from the room. 3. Explain that the man must leave the room while the nurse checks the client. 4. Give the client a brochure with information about a woman's shelter.

Tell the man the client needs to go to the x-ray department.

The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first? 1. The client diagnosed with agoraphobia who is calling to cancel the clinic appointment. 2. The client diagnosed with a somatoform disorder who has numbness in both legs. 3. The client diagnosed with hypochondriasis who is afraid she may have breast cancer. 4. The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.

The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.

The charge nurse received laboratory data for clients in the psychiatric unit. Which client data warrants notifying the psychiatric healthcare provider? 1. The client on lithium (Eskalith) whose serum lithium level is 1.0 mEq/L. 2. The client on clozapine (Clozaril) whose white blood cell count is 13,000. 3. The client on alprazolam (Xanax) whose potassium level is 3.7 mEq/L. 4. The client on quetiapine (Seroquel) whose glucose level is 128 mg/dL.

The client on clozapine (Clozaril) whose white blood cell count is 13,000.

Which client should the psychiatric clinic nurse assess first? 1. The client with long-term alcoholism who wants to stop drinking. 2. The client who is a cocaine abuser who is having chest discomfort. 3. The client with obsessive-compulsive disorder who won't quit washing his hands. 4. The client who thinks she was given "the date rape drug" and was raped last night.

The client who is a cocaine abuser who is having chest discomfort.

The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. Which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager? 1. The nurse provides the client with phone numbers to call if needing assistance. 2. The nurse makes the client a follow-up appointment in the psychiatric clinic. 3. The nurse gives the client a prescription for a 1-month supply of antidepressants. 4. The nurse tells the client not to take any over-the-counter medications.

The nurse gives the client a prescription for a 1-month supply of antidepressants.

The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider.

1

The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? 1. Systems that make it difficult for the nurses to do their job. 2. How unhappy the nurses are with their current pay scale. 3. Collective bargaining activity at a nearby hospital 4. The number of medication errors committed by an individual nurse.

1

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. 2. The client diagnosed with pneumonia who has an oral temperature of 100.2°F. 3. The client diagnosed with cystitis who complains of burning on urination. 4. The client diagnosed with pancreatitis who complains of pain that is an 8.

1

The psychiatric nurse overhears a mental health worker (MHW) arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement? 1. Ask the MHW to go to the nurse's station. 2. Tell the MHW to quit arguing with the client. 3. Notify the clinical manager of the psychiatric unit. 4. Report this behavior to the client abuse committee.

1

Which situation would prompt the healthcare team to utilize the client's advance directive when needing to make decisions for the client? 1. The client with a head injury who is exhibiting decerebrate posturing. 2. The client with a C-6 spinal cord injury (SCI) who is on a ventilator. 3. The client in chronic renal disease who is being placed on dialysis. 4. The client diagnosed with terminal cancer who is mentally retarded.

1

The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

1

The clinical manager wants to reward the staff on the psychiatric unit for having no tardies or absences for 1 month. Which action would be most appropriate for the clinical manager? 1. Provide pizza, drinks, and dessert for all the shifts. 2. Post a thank you note on the board in the employee lounge. 3. Individually acknowledge this accomplishment with the staff. 4. Place official documentation in each staff's employee file.

1

The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.

3

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. 2. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. 3. The client with renal calculi who is complaining of severe flank pain and has hematuria. 4. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia.

3

The nurse is working in an outpatient psychiatric clinic. The male client tells the nurse, "I am going to kill my wife if she files for divorce. I know I can't live without her." Which action should the nurse implement? 1. Take no action because this is confidential information. 2. Document the statement in the client's nurse's notes. 3. Inform the client's psychiatric healthcare provider (HCP) of the comment. 4. Encourage the client to talk to his wife about the divorce.

3

The psychiatric nurse is caring for clients on a closed unit. Which client would warrant immediate intervention by the nurse? 1. The client who refuses to attend the anger management class. 2. The client who is requesting to go outside to smoke a cigarette. 3. The client who is nauseated and has vomited twice. 4. The client who has her menses and has abdominal cramping.

3

The psychiatric unit staff is upset about the new female charge nurse who just sits in her office all day. One of the staff members informs the clinical manager about the situation. Which statement by the clinical manager indicates a laissez-faire leadership style? 1. "I will schedule a meeting to discuss the concerns of the charge nurse." 2. "I hired the new charge nurse and she is doing what I told her to do." 3. "You and the staff really should take care of this situation on your own." 4. "I will talk to the charge nurse about your concerns and get back to you."

3

Which situation requires priority intervention on an inpatient psychiatric unit? 1. A client is threatening to throw the television at another client. 2. A male client wants to use the phone to call his spouse. 3. A client sitting in a chair is delusional and hallucinating. 4. A client has refused to eat anything for the last 2 days.

3

The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the licensed practical nurse (LPN)? 1. The 6-year-old client diagnosed with sickle cell crisis. 2. The 8-year-old client diagnosed with biliary atresia. 3. The 10-year-old client diagnosed with anaphylaxis. 4. The 11-year-old client diagnosed with pneumonia.

4

The client enters a mental health clinic with a gun and is threatening to kill the nurse who told his wife to leave him. Which action should the nurse implement first? 1. Instruct a staff member to call the local police department. 2. Evacuate the clients and staff to a safe and secure place. 3. Encourage the client to talk about his feelings of anger. 4. Calmly and firmly ask the man to put the gun down on the floor.

4

The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheel- chair. Which priority action should the HH nurse tell the HH aide? 1. Explain how to perform isometric exercises. 2. Instruct her to go to the local emergency room. 3. Tell her to complete an occurrence report. 4. Recommend that she apply an ice pack to the back.

4

The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

4

The new nurse on the psychiatric unit tells the charge nurse, "I don't like how the shift report is given." Which statement is the charge nurse's best response? 1. "Since you're new I think you should try it our way before making any comments." 2. "We have been doing the shift report this way since I started working here more than 5 years ago." 3. "Have you discussed your concerns about the shift report with the other nurses?" 4. "I would be happy to listen to any ideas you have on how to give the shift report."

4

The nurse answers the client's phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement? 1. Ask the caller who is asking for Mr. Jones. 2. Tell the caller Mr. Jones cannot have phone calls. 3. Request the caller to give the access code for information. 4. Find Mr. Jones and tell him he has a phone call.

4

Which task would be inappropriate for the psychiatric charge nurse to delegate to the mental health worker (MHW)? 1. Instruct the MHW to escort the client to the multidisciplinary team meeting. 2. Ask the MHW to stay in the day room and watch the clients. 3. Tell the MHW to take care of the client on a 1-to-1 suicide watch. 4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.

4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.

Which nursing intervention is priority for the client diagnosed with anorexia who is admitted to an inpatient psychiatric unit? 1. Obtain the client's weight. 2. Assess the client's laboratory values. 3. Discuss family issues and health concerns. 4. Teach the client about selective serotonin reuptake inhibitors.

Assess the client's laboratory values.

The nurse is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse? 1. The 10-year-old child diagnosed with oppositional defiant disorder who refuses to follow the directions of the mental health worker (MHW). 2. The 5-year-old child diagnosed with pervasive developmental disorder who refuses to talk to the nurse and will not make eye contact. 3. The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room. 4. The 8-year-old mentally retarded child who is sitting on the playground and eating dirt and sand.

The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room.

Which behavior by the mental health worker (MHW) is an example of assault requiring immediate intervention by the psychiatric nurse? 1. The MHW injures a client who is forcibly being put in the "quiet" room. 2. The MHW refuses to let the client come into the day room until putting on socks. 3. The MHW escorts the client to the anger management class in another building. 4. The MHW threatened to forcibly remove the client who is refusing to get out of the bed.

The MHW threatened to forcibly remove the client who is refusing to get out of the bed.

The nurse on the substance abuse unit is administering medications. For which client would the nurse question administering the medication? 1. The client admitted for alcohol detoxification who is receiving lorazepam (Ativan) and has an apical pulse of 110. 2. The client admitted for heroin addiction who is receiving methadone (Methadose) and has a respiratory rate of 22. 3. The client admitted for opioid withdrawal who is receiving clonidine (Catapres) and has a blood pressure (BP) of 88/60. 4. The client diagnosed with Wernicke-Korsakoff syndrome receiving intravenous thiamine (vitamin B1) who has an oral temperature of 96.8ÆF.

The client admitted for opioid withdrawal who is receiving clonidine (Catapres) and has a blood pressure (BP) of 88/60.

Which client should the psychiatric charge nurse assign to the nurse from the surgical unit who was assigned to the psychiatric unit for the shift? 1. The client diagnosed with schizophrenia who is hallucinating and delusional. 2. The client with bipolar disorder who is manic and aggressive toward staff and clients. 3. The client who is diagnosed with chronic depression and will not talk to anyone. 4. The client with schizophrenia and an Axis 2 antisocial personality.

The client who is diagnosed with chronic depression and will not talk to anyone.

The psychiatric nurse is assessing the Abnormal Involuntary Movement Scale (AIMS) for clients on antipsychotic medications. Which client's scores require immediate intervention?

The client who scored a 24 on the scale.

The psychiatric nurse is working in an outpatient mental health clinic. Which client should the nurse intervene with first? 1. The client who had a baby 2 months ago and who is sitting alone and looks dejected. 2. The client whose wife just died and who wants to go to heaven to be with her. 3. The client whose mother brought her to the clinic because the mother thinks the client is anorexic. 4. The client who is rocking compulsively back and forth in a chair by the window.

The client whose wife just died and who wants to go to heaven to be with her.

The charge nurse has assigned the licensed practical nurse (LPN) to administer medications to the clients on an inpatient psychiatric unit. Which client should the LPN force to take the prescribed medications? 1. The client with bipolar disorder who has been declared incompetent in a court of law. 2. The client with major depression who voluntarily admitted herself to the unit. 3. The client with paranoid schizophrenia who was involuntarily admitted to the unit. 4. The client with a borderline personality who has legal charges pending in the court.

The client with bipolar disorder who has been declared incompetent in a court of law.