NUR 2120 Exam #2 Practice Questions
A nurse manager is discussing the care of a patient who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "Self-assessment will help me cope with emotional reactions to client care." C. "I should practice limit-setting to help prevent client manipulation." D. "Maintaining professional boundaries is a priority of client care."
A. "I can promote my client's sense of control by establishing a schedule."
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding? A. "I should expect tremors to start less than 24 hours after I stop drinking." B. "Disulfiram will block my cravings for alcohol." C. "My symptoms should last about 5 to 7 days once they begin." D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
A. "I should expect tremors to start less than 24 hours after I stop drinking." Signs of withdrawal might develop within a few hours of the client's last drink of alcohol
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client? A. "I will assist you in getting out of bed and getting dressed." B. "You can remain in bed until you feel well enough to join the group." C. "The unit rules state that you may not remain in bed." D. "If you don't participate in your care, you will not get better."
A. "I will assist you in getting out of bed and getting dressed."
A nurse is caring for a patient who has avoidant personality disorder. Which of the following statements is expected from a patient who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."
A. "I'm scared that you're going to leave me." Patients with avoidant personality disorder often shy away from social interactions and have a fear of abandonment
A client begins attendance at AA meetings. Which of the following statements made by the client reflects the purpose of this organization? A. "They claim they will help me stay sober." B. "I'll dry out in AA, then I can have a social drink now and then." C. "AA is only for people who have reached the bottom." D. "If I lose my job, AA will find me another."
A. "They claim they will help me stay sober."
A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching? A. "You should change positions slowly while taking this medication." B. "This medication is prescribed to help overcome alcohol addiction." C. "You should omit foods containing oxalates while taking phenalzine." D. "You should avoid drinking liquids after your evening meal."
A. "You should change positions slowly while taking this medication."
A nurse on a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy? A. A client who has been taking amitriptyline for 3 months of depression B. A client exhibiting psychotic behavior C. A client admitted 12 hours ago for mania D. A client who is experiencing alcohol intoxication
A. A client who has been taking amitriptyline for 3 months of depression
What are the steps in the continuum of escalation, in order? A. Calm, anxious, agitated, aggressive, violent B. Calm, agitated, violent C. Agitated, aggressive, violent D. Agitated, anxious, violent
A. Calm, anxious, agitated, aggressive, violent
What are the three central components of the model for caring behavior? A. Care of the self, care of each other, and care for patients B. Care of hope, care of life, and care of eternity C. Caring behavior of now, caring behavior of the future, caring behavior of yesterday D. All of the above
A. Care of the self, care of each other, and care for patients
A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply). A. Contact the laboratory to obtain a blood sample. B. Prepare the client for a CT scan. C. Check the client's pupil reactivity. D. Obtain a urine specimen. E. Perform a developmental screening test.
A. Contact the laboratory to obtain a blood sample. B. Prepare the client for a CT scan. C. Check the client's pupil reactivity. D. Obtain a urine specimen.
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention? A. Determine the presence and degree of suicidal risk. B. Assist the client to identify negative effects of chemical dependency. C. Identify support groups in the community for long-term treatment. D. Refer the client to a mental health care provider for evaluation and treatment.
A. Determine the presence and degree of suicidal risk
A charge nurse is preparing a staff education session on personality disorders. Which of the following should be included as personality characteristics associated with all of the personality disorders? (Select all that apply). A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other people E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A. Difficulty in getting along with other members of a group C. Display of defense mechanisms when routines are changed E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the nurse prepare to administer? A. Methadone B. Disulfiram C. Risperidone D. Lithium carbonate
A. Methadone Methadone is a synthetic opiate that blocks the craving for and the effects of narcotics; it is widely used to assist with detoxification and maintenance of those who have a dependency to opioids
What are the main types of conflict? A. Overt and covert B. Active and passive C. A and B D. None of the above
A. Overt and covert
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurses priority? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects
A. Placing the client on one-to-one observation This is during admission, so we don't know anything other than the diagnoses which indicates risk for suicide
A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply.) A. Request an ECG. B. Witness the informed consent. C. Check the client's blood pressure. D. Obtain a serum parathyroid hormone level. E. Obtain a urine specimen.
A. Request an ECG. B. Witness the informed consent. C. Check the client's blood pressure. Baseline ECG allows the provider to identify cardiac changes that can occur during ECT; informed consent is required prior to ECT; baseline blood pressure allows the provider and nurse to identify cardiac stress that can occur during ECT
A patient is admitted to the hospital after an extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Lab reports reveal that he has a BAC of .25 mg/DL. He is placed on the chemical addictions unit for detoxification. When would the first signs of alcohol withdrawal symptoms be expected to occur? A. Several hours after the last drink B. 2 to 3 days after the last drink C. 4 to 5 days after the last drink D. 6 to 7 days after the last drink
A. Several hours after the last drink
Which of the following is the best predictor of future violence? A. Stone silence B. Joining in during group C. Communicating with the nurse D. Disheveled clothing
A. Stone silence
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A. The client runs 4 miles outdoors every afternoon. B. The client drinks 2 liters of liquids daily. C. The client eats 2 to 3 gm of sodium-containing foods daily. D. The client eats foods high in tyramine.
A. The client runs 4 miles outdoors every afternoon
A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should the nurse expect? A. Tremors B. Hypothermia C. Hypotension D. Respiratory depression
A. Tremors Manifestations of acute cocaine toxicity include tremors, agitation, and seizures
Behavioral restraints or seclusion should only be used when all other interventions have been tried. A. True B. False
A. True
Only the team leader should talk with the patient during crisis management. A. True B. False
A. True
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? A. "Of course people care. Your family comes to visit every day." B. "Why do you feel that way?" C. "Tell me who you think doesn't care about you." D. "I care about you, and I am concerned that you feel so sad."
D. "I care about you, and I am concerned that you feel so sad."
A nurse is reinforcing teaching with an older adult client who has major depressive disorder and a prescription for nortriptyline 25 mg daily. Which of the following client statements indicates understanding of the teaching? A. "I should take my nortriptyline before breakfast." B. "I can no longer eat pepperoni pizza." C. "I will avoid drinking caffeinated beverages." D. "I should sit on the side of the bed before standing up in the morning."
D. "I should sit on the side of the bed before standing up in the morning."
A nurse is discussing the use of methadone (Dolophine) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Methadone is a replacement for the patient's opined addiction." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the patient's risk for acetaldehyde syndrome."
D. "Methadone increases the patient's risk for acetaldehyde syndrome."
A nurse is admitting a patient who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the patient's adult daughter, which of the following statements is the highest priority to report to the provider? A. "My mother has diabetes that is controlled by diet" B. "My mother recently completed a course of prednisone for acute bronchitis" C. "My mother received her flu vaccine last month" D. "My mother is currently on furosemide for her congestive heart failure"
D. "My mother is currently on furosemide for her congestive heart failure" Diuretics can cause lithium toxicity
A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry." B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You better listen to me."
D. "You better listen to me."
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate? A. "You are being unreasonable, and I will not call your doctor at this hour." B. "Go back to your room, and I'll try to get in touch with your doctor." C. "I can't call a doctor in the middle of the night unless it's an emergency." D. "You must be very upset about something."
D. "You must be very upset about something."
A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "You will need to consume a low-salt diet while on this medication." B. "You will need your blood levels drawn weekly during the first month." C. "You will need to take this medication on an empty stomach." D. "You will need to stop this medication if you experience diarrhea."
D. "You will need to stop this medication if you experience diarrhea."
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? A. "You have a great deal to live for." B. "It's not unusual for depressed people to feel that way." C. "Why do you feel you are worthless?" D. "You've been feeling that your life has no meaning."
D. "You've been feeling that your life has no meaning."
Which of the following is a de-escalation technique for difficult patients? A. Encouraging the patient to engage in relaxation exercises B. Offering choices and educating the patient C. Ignoring the patient D. A and B
D. A and B
Which of the following is a technique used in crisis intervention? A. Develop an alliance B. Gather information and problem-solve C. Open-ended D. A and B E. None of the above
D. A and B
A nurse in the emergency department is planning care for a client who is admitted for an overdose of phencyclidine (PCP). Which of the following actions should the nurse plan to take? A. Administer warmed IV fluids to counteract hypothermia. B. Reverse the toxicity with naloxone. C. Verbally attempt to calm the client. D. Administer ammonium chloride.
D. Administer ammonium chloride Ammonium chloride acidifies the urine and promotes excretion of PCP
What is the most common type of mental health emergency that presents to emergency departments? A. Suicide B. Domestic violence C. Alcohol/substance abuse D. All of the above
D. All of the above
Which of the following are safety techniques used during de-escalation? A. Using a buddy system and paying attention to your surroundings B. Giving the patient room and being aware of your body language C. Standing close to a door for safety D. All of the above
D. All of the above
Which of the following is a de-escalation technique? A. Encourage the agitated person to verbalize (ventilation) B. Encourage the agitated person to watch TV or listen to the radio C. Offer the agitated person a meal, snack, or beverage D. All of the above
D. All of the above
Which of the following is an effective de-escalation intervention for an individual with major neurocognitive disorder (dementia)? A. Encouraging verbalization B. Having the patient do isometric exercises C. Reminiscence therapy D. All of the above
D. All of the above
Which of the following is an intervention to prevent escalation to non-suicidal self-injury (NSSI)? A. Having the patient wear a loose rubber band around the wrist B. Encouraging the patient to engage in physical exercise C. Encouraging the patient to write D. All of the above E. None of the above
D. All of the above
Who participates in a post-aggression episode debriefing? A. Patient B. Staff C. Family members involved in episode D. All of the above
D. All of the above
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? A. Lock the doors to the unit and secure windows so they cannot be opened. B. Provide the client with plastic eating utensils for meals. C. Remove any objects from the client's environment that could be used for self-harm. D. Assign a staff member to stay with the client at all times.
D. Assign a staff member to stay with the client at all times
A nurse educator is discussing community mental health with a group of nursing students. Which of the following sites should the educator identify as a source of secondary prevention? A. Day care center B. Outpatient rehabilitation center C. Community recreational center D. Crisis center
D. Crisis center
A nurse is caring for a patient who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. Assign the patient to a private room B. Document the patient's behavior every hour C. Allow the patient to keep perfume in her room D. Ensure that the patient swallows medication
D. Ensure that the patient swallows medication Make sure that the patient is not saving their medication to overdose on later; a private room is not necessary and the patient should be on a 1:1 with documentation every 15 minutes
What is an environmental cause of aggression or violence? A. Pollution B. Private room C. Room window with view of nature D. Excessive noise
D. Excessive noise
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority? A. Vitamin deficiency B. Diaphoresis C. Tremors D. Illusions
D. Illusions
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action? A. Identifying support systems B. Assisting the client in identifying coping behaviors C. Encouraging self-care D. Preventing self-directed violence
D. Preventing self-directed violence
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? A. Enroll the client in a nutritional class on the unit. B. Weigh the client at the same time every morning. C. Ask provider to arrange a consultation with the facility chaplain. D. Sit with the client during meals and snacks.
D. Sit with the client during meals and snacks
Which of the following is not an effective technique for de-escalating anger? A. Progressive muscular relaxation B. Time-out (counting to 10 before reacting) C. Encouraging the patient to verbalize issues D. Skipping meals
D. Skipping meals
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority? A. The client will acknowledge alcohol dependence and need for treatment. B. The client will rebuild damaged interpersonal relationships. C. The client will implement alternative strategies for managing anxiety. D. The client's withdrawal from alcohol will be managed without complications.
D. The client's withdrawal from alcohol will be managed without complications The greatest risk to the client is injury and adverse effects of withdrawal
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."
B. "I am here to provide care and cannot accept this from you." Setting boundaries is important ; C would feed into their grandiose thoughts and poor financial judgment
A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply). A. "I exercise aerobically three times a day for 30 minutes." B. "I get 7 hours of sleep at night by skipping afternoon naps." C. "I think about being on my favorite beach vacation when I get anxious." D. "I tense and relax my muscles starting with my feet." E. "I see the glass is half-full when it starts looking empty."
B. "I get 7 hours of sleep at night by skipping afternoon naps." C. "I think about being on my favorite beach vacation when I get anxious." D. "I tense and relax my muscles starting with my feet." E. "I see the glass is half-full when it starts looking empty."
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make? A. "It might help you feel better if you talk about it." B. "I'll just sit here with you for a few minutes then." C. "I understand. I've felt like that before, too." D. "Why are you feeling so down?"
B. "I'll just sit here with you for a few minutes then."
A nurse is caring for a patient who is on lithium therapy. The patient states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements by the nurse is appropriate? A. "That is a good choice. ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."
B. "Regular aspirin would be a better choice than ibuprofen." NSAIDs with the exception of aspirin are contraindicated with lithium
A nurse is evaluating a patient's understanding of a new prescription of clonidine (Catapres). Which of the following statements by the patient indicates an understanding of the teaching? A. "Taking this medication will help reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea because of taking this medication." D. "Each dose of this medication should be placed under my tongue to dissolve."
B. "While taking this medication, I should keep a pack of sugarless gum."
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer the morning dose of lithium. C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Hold the medication and assess for early manifestations of toxicity
B. Administer the morning dose of lithium
25. A nurse is planning care for a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following medications should the nurse anticipate administering prior to the procedure? A. Diphenhydramine B. Atropine C. Epinephrine D. Fluoxetine
B. Atropine
Which of the following medications is the physician most likely to order for a client experiencing alcohol withdrawal syndrome? A. Haloperidol (Haldol) B. Chlordiazepoxide (Librium) C. Methadone (Dolophine) D. Phenytoin (Dilantin)
B. Chlordiazepoxide (Librium)
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect? A. Nystagmus B. Dilated pupils C. Hypersomnia D. Depression
B. Dilated pupils Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system
What is an example of assertive behavior? A. Putting another person's needs first B. Directly and respectfully communicating needs C. Not listening to others D. Allowing others to take control
B. Directly and respectfully communicating needs
Behavioral restraints can be a PRN order. A. True B. False
B. False
A nurse is assessing a patient who has alcohol use disorder and is experiencing withdrawal. Which of the following is an expected finding? (Select all that apply). A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness
B. Fine tremors of both hands D. Vomiting E. Restlessness
A patient says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment? A. Patient's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Patient's insight into the reasons for the decision
B. Lethality of the method and availability of means These things could increase a patient's risk for suicide even further
Ms. Kim is on an inpatient medical/surgical floor after kidney stones led to possible acute kidney injury. Which of her home medications should the nurse hold and for what test to determine safety? A. Lithium, awaiting ultrasound of bladder B. Lithium, awaiting a 24 hour urine test with creatinine clearance C. Cymbalta, awaiting a CD4 count and viral load D. Cymbalta, awaiting a liver enzyme panel
B. Lithium, awaiting a 24 hour urine test with creatinine clearance Cymbalta is not filtered by the kidneys and has nothing to do with CD4 or viral load; bladder ultrasound will not give significant useful information
A nurse is planning care for a client who is being treated for acute phencyclidine (PCP) intoxication. Which of the following should the nurse include in the plan of care? A. Engage the client in a physical diversion. B. Monitor for hypertension. C. Provide a warming blanket. D. Maintain access to flumazenil.
B. Monitor for hypertension The client should be monitored for elevation of blood pressure due to the increased risk of hypertensive crisis
Which of the following is not a principle of de-escalation? A. Remaining calm B. Offering multiple choices C. Using correct paraverbals D. Remaining nonjudgmental
B. Offering multiple choices
When does violence prevention truly begin? A. On the day of discharge B. On the first day a patient enters a healthcare facility C. One week after inpatient admission D. All of the above
B. On the first day a patient enters a healthcare facility
What areas are the focus of a comprehensive healthcare violence prevention plan? A. Day, week, and year B. Patient, caregiver, and environment C. Past, present, and future D. None of the above
B. Patient, caregiver, and environment
A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. Which of the following is an expected finding? A. Family history of Alzheimer's disease B. Personal history of alcohol use disorder C. Undergoing current treatment for HIV D. Current rehabilitation for opiate addiction
B. Personal history of alcohol use disorder
A nurse is discussing early indications of toxicity with a patient who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following in the teaching? (Select all that apply). A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus
B. Polyuria D. Muscle weakness
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Confronting the use of denial and other defense mechanisms D. Educating the client about the consequences of alcohol misuse
B. Providing for adequate hydration and rest Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client
B. Request that other staff members remain close by
A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification
B. Splitting
A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. You suspect depression. What is the rationale for performing a mini-mental status exam? A. To rule out schizophrenia B. To rule out dementia C. To rule out an anxiety disorder D. To rule out thyroid problems
B. To rule out dementia Thyroid problems wouldn't be related to general mental status; schizophrenia and anxiety disorders cannot be ruled out by an MMSE
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply). A. Severe hypotension B. Visual hallucinations C. Hyperglycemia D. Insomnia E. Tremors
B. Visual hallucinations D. Insomnia E. Tremors Visual and auditory hallucinations are expected findings with alcohol withdrawal; insomnia, restlessness, irritability, and tremors are common manifestations of alcohol withdrawal
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing the client, which of the following are expected findings? (Select all that apply). A. Demonstrates extreme anxiety when placed in a social situation B. Has difficulty making even simple decisions C. Attempts to convince others clients to give him their belongings D. Becomes agitated if his personal area is not neat and orderly E. Blames others for his past and current problems
C. Attempts to convince others clients to give him their belongings E. Blames others for his past and current problems Clients with antisocial personality disorder are manipulative and fail to accept personal responsibility
Which of the following is an effective way to prevent escalation with patients with delirium? A. Shouting loudly B. Providing a calm environment C. B and D D. Building a positive relationship with the patient
C. B and D
What is the worst type of stress? A. Morning stress B. Neustress C. Chronic stress D. Covert stress
C. Chronic stress
What milieu characteristic is not a predictor of violence? A. Staff inexperience B. Poor limit setting C. Consistent staff members D. Overcrowding
C. Consistent staff members
A patient who you know is taking an MAOI is discussing what foods they take during a nutritional coaching session. Which of the following foods they name is of the highest concern and should be addressed promptly by the nurse? A. Lettuce B. Cottage cheese C. Corned beef D. Potato salad E. Corn
C. Corned beef Lettuce, corn, and potato salad are all fresh and not high in tyramine; cottage cheese is not fermented or aged so it is not high in tyramine; corned beef is a cured product and thus high in tyramine
A nurse is planning care for a patient who is experiencing benzodiazepine withdrawal. Which of the following is the priority nursing intervention? A. Orient the patient frequently to time, place, and person B. Offer fluids and nourishing diet as tolerated C. Implement seizure precautions D. Encourage participation in group therapy sessions
C. Implement seizure precautions
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication? A. Thyroid function tests should be performed every 6 months. B. A pretreatment electroencephalogram (EEG) will be done. C. Liver function tests must be monitored. D. High serum sodium levels can cause toxic levels of valproate.
C. Liver function tests must be monitored
Which of the following is not a safety risk? A. Confronting the patient B. A nurse wearing large hoop earrings C. Maintaining appropriate (physical and verbal) boundaries with the patient D. Ignoring the patient
C. Maintaining appropriate (physical and verbal) boundaries with the patient
A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care? A. Encourage family to take the client out of the facility for short periods of time. B. Reward the client for her change in behavior. C. Monitor the client's whereabouts at all times. D. Ask the client why her behavior has changed.
C. Monitor the client's whereabouts at all times Clients who have depression and exhibit a sudden change in behavior are at a risk for suicide and suicide precautions should be included in the plan of care
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings B. Maintain eye contact with the patient C. Move the client away from others D. Tell the client that the behavior is not acceptable
C. Move the client away from others
A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use rationalization to cope with a substance use disorder C. Older adults are at a higher risk for substance use following retirement D. Older adults develop substance use to mask signs of dementia
C. Older adults are at a higher risk for substance use following retirement
You are working on an inpatient psychiatry floor when a patient is admitted with major depressive disorder, severe, who has been having deficits in self-care activities. Which of the following is a good goal for the first day of nursing care. A. Patient will attend dance therapy group and participate B. Patient will not leave room and will be searched regularly for sharp objects C. Patient will attend meals in common area with nurse D. Patient will feel better
C. Patient will attend meals in common area with nurse Is an achievable goal that encourages social engagement and daily life activities; A is difficult to achieve on a first meeting; D is too vague; B is wrong because there is no evidence of suicidal ideation and isolation will be damaging to mental health
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first? A. Implement seizure precautions. B. Insert an IV access site. C. Perform a neurological exam. D. Obtain a blood specimen.
C. Perform a neurological exam
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention? A. Administering an anticonvulsant. B. Padding side rails to prevent injury. C. Preparing for artificial ventilation. D. Applying a cooling blanket.
C. Preparing for artificial ventilation
What mental disorder involves prevalent and markedly disturbing hallucinations and delusions? A. Bipolar disorder B. Major depressive disorder C. Schizophrenia D. Panic disorder
C. Schizophrenia
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take? A. Warn the client that further disruptions will result in seclusion. B. Ignore the client's behavior, realizing it is consistent with her illness. C. Set limits on the client's behavior and be consistent in approach. D. Ask the client to recommend consequences for her disruptive behavior.
C. Set limits on the client's behavior and be consistent in approach
A nurse is providing teaching to the family of a patient who has a substance use disorder. Which of the following statements by a family member indicates a need for further teaching? A. "We need to understand that she is not responsible for her disorder." B. "Eliminating any codependent behavior will promote her recovery." C. "She should participate in an Alcoholics Anonymous group to help her recover." D. "The primary goal of her treatment is abstinence from substance use."
C. She should participate in an Alcoholics Anonymous group to help her recover
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take? A. Turn on a dance video so the client can burn off excess energy. B. Offer the client a low-calorie snack in return for stopping the behavior. C. Take the client outside and sit with her in the garden area. D. Observe the client closely for the development of aggressive behavior
C. Take the client outside and sit with her in the garden area Remove the client from the stimulating environment and use instruction, rather than bargaining, to decrease activity level
A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? A. Recommend a game of table tennis with another client. B. Suggest the client exercise on a stationary bike. C. Take the client outside for a walk. D. Praise the client's efforts to engage in social interaction.
C. Take the client outside for a walk
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? A. The client's spouse reports that client has recently gained weight. B. The client is dressed in all black. C. The client responds to questions with disorganized speech. D. The client reports that voices are telling him to write a novel.
C. The client responds to questions with disorganized speech
A nurse is reviewing the medical record of a patient who has a new prescription for bupropion (Wellbutrin) for depression. Which of the following findings is the highest priority for the nurse to report to the provider? A. The patient has a family history of seasonal pattern depression B. The patient current smokes 1.5 packs of cigarettes per day C. The patient had a motor vehicle crash last year and sustained a head injury D. The patient has a BMI of 25 and gained 10 lbs over the last year
C. The patient had a motor vehicle crash last year and sustained a head injury This medication can lower the seizure threshold and therefore should be avoided by someone who has had a head injury, which could lower the seizure threshold even further
What are the two types of therapeutic communication? A. Open and closed B. Difficult and complex C. Verbal and nonverbal D. All of the above
C. Verbal and nonverbal
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent the relapse of bipolar disorder."
C. "ECT is effective for clients who are experiencing severe mania." ECT is not a first line treatment; it is used to treat acute episodes, not to prevent relapse; ECT is most commonly used to treat depression, but can also be used for mania
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts? A. "I am responsible for my alcoholism." B. "I need to identify things that cause me to be an alcoholic." C. "I am powerless against my addiction to alcohol." D. "I need to see a counselor who will be responsible for my recovery."
C. "I am powerless against my addiction to alcohol."
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? A. "I'm sure that the bugs you see will not harm you." B. "Tell me more about the bugs that you see in your room." C. "I don't see any bugs, but you seem very frightened." D. "I do not see anything. This is part of the withdrawal process."
C. "I don't see any bugs, but you seem very frightened."
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? A. "I journal when I find it difficult to talk." B. "I pray when I begin to breathe fast." C. "I fix myself a pot of coffee when I get anxious." D. "I exercise when my neck is tense."
C. "I fix myself a pot of coffee when I get anxious."
Which statement by a patient with a history of major depression indicates a need for further assessment of mental health status? A. "I had a great trip to the Smoky Mountains. It was fun." B. "Going back to work, well, it's not bad; it's ok." C. "I just don't like going to the movies like I did before." D. "I can't wait to go to my son's wedding next weekend. It will be nice to have the whole family together."
C. "I just don't like going to the movies like I did before." Indicates that the patient is having trouble enjoying things, a sign of a depressed state; A and D raise no concerns; B indicates that there may be problems but requires further assessment (maybe their job is just not great)
A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the client indicates understanding of the teaching? A. "I may develop a slow heartbeat while taking bupropion." B. "I can drink one glass of wine with dinner each day while taking bupropion." C. "I may not notice a lifting of my mood for at least 2 weeks." D. "I should watch for increased salivation and drooling while taking bupropion."
C. "I may not notice a lifting of my mood for at least 2 weeks."
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding? A. "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol." B. "Alcohol tolerance causes me to have an increased effect when taking opiates." C. "I will develop a decreased physical response to alcohol." D. "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal."
C. "I will develop a decreased physical response to alcohol." A client can develop alcohol tolerance due to repeated exposure to the substance and can have a decreased physical response
A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make? A. "You really need to follow the rules of the unit and get out of bed." B. "If you do not get out of bed you will not receive your meal." C. "I will help you get ready and then you can rest after activities." D. "You should rest until you feel able to join the group."
C. "I will help you get ready and then you can rest after activities." This statement shows caring by the nurse and provides balance between activity and rest, which is an appropriate intervention for a client with depression
You are preparing a patient for electroconvulsive treatments that they will receive in an hour. Which of the following statements indicate you must conduct further assessment to ensure patient safety around ECT? A. "I took a shower last night so that I could go right to the procedure today." B. "My partner won't be there and that makes me anxious." C. "My dental implants started aching last night." D. "I just got a call from my son that he changed his cell number. I'll have to remember that after the procedure."
C. "My dental implants started aching last night." Other answers are not related to safety; taking a shower the night before is best practice so their hair is not wet during the procedure
Which of the following is a critical element of the de-escalation process? A. Assessment and safety B. De-escalation techniques C. Debriefing D. Reporting and documenting E. All of the above
E. All of the above
