Psych review

a nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. the nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. Which of the following types of treatment is this method an example? a. aversion therapy B.Flooding c.Biofeedback d. dialectical behavior therapy

a. aversion therapy

a nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? a. discussing ways to use new behaviors B. practicing new problem-solving skills C. developing goals d. establishing boundaries

a. discussing ways to use new behaviors

a nurse is working in a community mental health facility. Which of the following services does this type of program provide? (select all that apply.) a. educational groups B. Medication dispensing programs c. individual counseling programs D. Detoxification programs e. Family therapy

a. educational groups B. Medication dispensing programs c. individual counseling programs e. Family therapy

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (select all that apply.) a.Priority restructuring B.Monitoring thoughts c. diaphragmatic breathing d.Journal keeping e.Meditation

a.Priority restructuring B.Monitoring thoughts d.Journal keeping

A nurse working on an acute mental health unit forms a group to focus on self‑management of medications. at each of the meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following concepts? a. Triangulation B. Group process C. Subgroup d. hidden agenda

d. hidden agenda

A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication? A. Offering advice B. Reflecting meaning C. Listening attentively D. Giving information

A. Offering advice Offering advice to a client is a barrier to therapeutic communication and should be avoided. Advice tends to interfere with the client's ability to make personal decisions and choices

A pt is diagnosed with an abscess in the cerebellum. Which nursing dx has the highest priority in the plan of care? A. Risk for falls r/t loss of balance and equilibrium B. Unilateral neglect r/t impairments to perception C. Impaired physical mobility r/t spasticity and changes in muscle tone D. Risk for impaired cerebral perfusion r/t obstruction secondary to infxn

A. Risk for falls r/t loss of balance and equilibrium

5. A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following is appropriate to include in the discussion? (Select all that apply.) A. The DSM-5 is used to identify mental health disorders. B. The DSM-5 establishes diagnostic criteria. C. The DSM-5 indicates recommended pharmacological treatment. D. The DSM-5 assists nurses in planning care. E. The DSM-5 indicates expected assessment findings.

A. The DSM-5 is used to identify mental health disorders. B. The DSM-5 establishes diagnostic criteria. D. The DSM-5 assists nurses in planning care. E. The DSM-5 indicates expected assessment findings. **DSM-5 does NOT indicate pharmacological treatment!

4. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding? A. The client arouses briefly in response to a sternal rub. B. The client has a Glasgow Coma Scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place.

A. The client arouses briefly in response to a sternal rub. A client who is stuporous requires vigorous or painful stimuli to elicit a response.

A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful? A. The student reports improved feelings of well-being B. The student increases use of caffeine to enhance concentration C. The student reports, "Now I am sleeping about 10 hours every day." D. The student says, " I withdrew from 2 courses to reduce my academic workload."

A. The student reports improved feelings of well-being

A nurse is planning care for a client following surgical implantation of a vagus nerve stimulation (VNS) device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply.) A. Voice changes B. Seizure activity C. Disorientation D. Dysphagia E. Neck pain

A. Voice changes D. Dysphagia E. Neck pain

A distraught 8 yo tells the school nurse, "I had a horrible nightmare and was so scared. I tried to get in bed with my parents but they said, 'No.' I think I could have gone back to sleep if I had been with them." Which family dynamic is likely the basis of this child's comment? A. boundaries in the family are rigid B. The family has poor differentiation roles C. The girl is enmeshed in part of a family triangle D. generational boundaries in the family are diffuse

A. boundaries in the family are rigid

A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion? A. excessive stressors cause the client to experience distress. B. the body's initial adaptive response to stress is denial. C. absence of stressors results in homeostasis. D. negative, rather than positive, stressors produce a biological response.

A. excessive stressors cause the client to experience distress.

A nurse plans for a patient diagnosed with borderline personality disorder. Which nursing diagnosis is most likely to apply to this patient? A. ineffective relationships r/t frequent splitting B. Social isolation r/t fear of embarrassment or rejection C. Ineffective impulse control r/t violence AEB cruelty to animals D. Disturbed thought processes r/t recurrent suspiciousness of people and situations.

A. ineffective relationships r/t frequent splitting

A nurse is teaching a client about stress‑reduction techniques. Which of the following client statements indicates understanding of the teaching? A."Cognitive reframing will help me change my irrational thoughts to something positive." B."Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C."Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D."Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A."Cognitive reframing will help me change my irrational thoughts to something positive."

A nurse is planning care for a client following surgical implantation of a VnS device. the nurse should plan to monitor for which of the following adverse effects? (Select all that apply.) A.Voice changes B.Seizure activity C.Disorientation D.Dysphagia E. neck pain

A.Voice changes D.Dysphagia E. neck pain

a nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? a. the client asks the nurse whether she will go out to dinner with him. B. the client accuses the nurse of telling him what to do just like his ex-girlfriend. C. the client reminds the nurse of a friend who died from a substance overdose. d. the client becomes angry and threatens harm to himself.

B. the client accuses the nurse of telling him what to do just like his ex-girlfriend.

A nurse analyzes reports from four adult patients of frightening events they encountered. Which patient's report most clearly indicates that the resulting fear was mentally healthy? A. "I saw a large spider crawling along my kitchen wall." B. "I was at the mall when a gun man began firing an assault weapon." C. "I was at home when a storm with heavy thunder and lightening lasted over an hour." D. "I was trapped on an elevator that stopped between floors when the power went out."

B. "I was at the mall when a gun man began firing an assault weapon."

A nurse is caring for a client in restraints. Which of the following statements are appropriate documentation? (Select all that apply.) A. "Client ate most of his breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted at assistive personnel." D. "Client received chlorpromazine (Thorazine) 15 mg by mouth at 1000." E. "Client acted out after lunch."

B. "Client was offered 8 oz of water every hr." C. "Client shouted at assistive personnel." D. "Client received chlorpromazine (Thorazine) 15 mg by mouth at 1000." These are all examples of objective data, which should all be documented. A and E are subjective data, and therefore are not appropriate to document.

The school nurse assesses four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity? A. 5'2" 104 lbs B. 5'7" 110 lbs C. 5'5" 114 lbs D. 5'8" 127 lbs

B. 5'7" 110 lbs

A mental health nurse assesses a pt diagnosed w an anti social personality disorder. Which comorbid problem is most important for the RN to include in the assessment? A. Generalized anxiety B. Alcohol use and abuse C. Compulsions and phobias D. Dysfunctional sleep patterns

B. Alcohol use and abuse

Systematic measurement of body wt, BMI, waist circumference, and glucose lvls would be most important for a pt beginning a new RX of: A. aripiprazole (Abilify) B. Olanzapine (Zyprexa) C. Ziprasidone (Geodon) D. Qetiapine (Seroquel)

B. Olanzapine (Zyprexa)

A neighbor telephones the nurse daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ? A. Suggest the neighbor call other people in the community. B. Say to the neighbor "I can talk to you for 15 mins twice a week" C. Use the telephone's caller identification to screen calls from the neighbor. D. Tell the neighbor, "You should discuss these concerns with your personal physician rather than me."

B. Say to the neighbor "I can talk to you for 15 mins twice a week"

An individual lives in a community adjacent to the military base. Loud jets fly overhead multiple times daily. The person tells the nurse, "They're so loud I can't hear myself think." What is the nurse's best action? A. Direct the individual to report the jet noise to the local authorities B. Teach relaxation and stress reduction techniques C. Assess the individual for sensory impairments, particularly auditory. D. Encourage the individual to form a community action group to oppose noise pollution.

B. Teach relaxation and stress reduction techniques The individual is experiencing physical stress from stressful environment (loud noises).

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

B. Tell the nurse to stop discussing the behavior.

A nurse plans a group meeting for adult patients in a therapeutic milieu. Which topic should the nurse include? A. coping with greif and loss B. The importance of hand washing C. Strategies for money management D. Staffing shortages expected over the next 3 days

B. The importance of hand washing A therapeutic milieu provides a healthy structure w/in an inpatient setting or structured outpatient settings. Groups aim to help increase the patients self esteem, decrease social isolation, encourage appropriate social behaviors, and educate patients in basic living skills, such as good hand washing.

Which pt would the nurse expect to have the most difficulty w problem solving and decision making? A. An 18 y/o diagnosed w bulimia nervosa at age 14; has taken oral doses of fluoxetine (Prozac) for 3 years. B. A 46 y/o diagnosed w schizophrenia at age 24; has taken oral doses of clozapine (Clozaril) daily for 18 years. C. A 62 y/o diagnosed w bipolar disorder at age 28; has taken oral divalproex sodium (Depakote) daily for 16 years. D. A 52 y/o diagnosed w schizophrenia at age 21; has taken monthly injections of haloperidol (Haldol decanoate) for 12 years.

D. A 52 y/o diagnosed w schizophrenia at age 21; has taken monthly injections of haloperidol (Haldol decanoate) for 12 years.

A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

D. Intonation

2. A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications

D. Monitor the client for adverse effects of medications

A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

D. Restating

A patient reports to the PCP about sleplessness, constant fatigue, and sadness. In our current health care climate, what is the most likely treatment approach that will be offered to the patient? A. group therapy B. individual psychotherapy C. complementary therapy D. psychopharmological therapy

D. psychopharmological therapy

a nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? a. demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator. c.Gradually expose the client to an elevator while practicing relaxation techniques. d. stay with the client in an elevator until his anxiety response diminishes.

c. Gradually expose the client to an elevator while practicing relaxation techniques.

a nurse is caring for several clients who are attending community‑based mental health programs. Which of the following clients should the nurse plan to visit first? a. a client who recently burned her arm while using a hot iron at home B. a client who requests that her antipsychotic medication be changed due to some new adverse effects c. a client who says he is hearing a voice that tells him he is not worthy of living anymore D. a client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview

c. a client who says he is hearing a voice that tells him he is not worthy of living anymore

a nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. the client's wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow‑up care? a. receiving daily care from a home health aide B.Having a weekly visit from a nurse case worker c. attending a partial hospitalization program D. visiting a community mental health center on a daily basis

c. attending a partial hospitalization program

a community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? a. educating clients on health promotion techniques to reduce the risk of depression B.Performing screenings for depression at community health programs c. establishing rehabilitation programs to decrease the effects of depression D.Providing support groups for clients at risk for depression

c. establishing rehabilitation programs to decrease the effects of depression

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply.) A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

B. Drooling C. Involuntary arm movements E. Continual pacing

A mature, professional couple plans a large wedding in a city 100 mile from home. Which response is most likely to be associated with this experience? A. Distress B. Eustress C. Acute stress D. Depersonalization

B. Eustress

a pt who is diagnosed w schizophrenia complains to the RN about persistant feelings of restlessness and says, "I feel like I need to move all the time." What is the RN's best action? A. add an activity group to the pts plan of care B. assess the pt for other EPS C. preform a full MSE D. educate the pt about psychomotor agitation associated w schizophrenia

B. assess the pt for other EPS

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 is the highest priority action by the nurse? 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

A pt smiles broadly at the RN and says, "Look at my clean teeth. I brushed them with scouring power because the label said it, "brightens and whitens everything." Which term should the RN include when documenting this encounter? A. circumstantiality B. concrete thinking C. poverty of speech D. associative looseness

B. concrete thinking

A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions are appropriate for the nurse to include in the assessment? (Select all that apply.) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"

A. "What is your relationship like with your family?" C. "Would you describe your current eating habits?" E. "Can you discuss your feelings about your appearance?"

3 weeks after being assulted by a pt, a RN develops headaches, insomnia, and GI problems. The RN has 4 absences from work over a 2-week period. Which action should the nursing supervisor employ? A. Refer the RN for counseling and support. B. Ask the RN about current personal problems. C. Direct the RN to take paid vacation for the following week. D. Schedule the RN for administrative tasks rather than pt care.

A. Refer the RN for counseling and support.

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements by the nurse are appropriate? (Select all that apply.) A. "When did you start hearing the voices?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself?" E. "Why are the voices talking to only you?"

A. "When did you start hearing the voices?" C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself?"

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following are expected findings? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

B. Family report of personality changes C. Hallucinations E. Restlessness

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client? (Select all that apply.) A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes E. Being married

A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes Dep more prevalant in adults 15-40 y/o 2x more common in F in that time period chronic medical illnesses increase risk substance use increases risk

A person shoplifts merchandise from a community cancer thrift shop. When confronted, the thief replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder? A. Antisocial B. Histrionic C. Borderline D. Schizotypal

A. Antisocial callousness, entitlement, lack of remorse, and disregard for rights of others are all typical of antisocial personality disorder

A pt diagnosed with schizophrenia says, "I hear the voices everyday. They always say bad things about me." Which action by the RN has the highest priority? A. Assess the pt for suicidal thinking and plans B. review the pts medication regimin and compliance C. educate the pt about symptoms associated with schizophrenia D. suggest distractors for the pt to use when auditory hallucinations occur

A. Assess the pt for suicidal thinking and plans

A nurse is assessing a client 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 veteran of the war in Afghanistan tells the RN, "Everyday something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life but I can't." What is the nurse's first priority? A. Assess the veteran for suicide risk B. Refer the veteran for specialized mental health services C. Assess the veteran for evidence of TBI D. Refer the veteran's family to a PTSD group

A. Assess the veteran for suicide risk

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

A. Auditory hallucination C. Use of clang associations D. Delusion of persecution E. Constantly waving arms hallucinations, delusions, alterations in speech, and bizarre behavior/movements are all positive symptoms

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following should the charge nurse identify as being effectively treated by conventional antipsychotics? (Select all that apply.) A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeur D. Severe agitation E. Anhedonia

A. Auditory hallucinations C. Delusions of grandeur D. Severe agitation

A nurse is obtaining a health history from the parents of a 12-year-old client who has conduct disorder. Which of the following are expected findings? (Select all that apply.) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Narcissistic behavior E. Flat affect

A. Bullying of others B. Threats of suicide C. Law-breaking activities

A nurse is caring for a client who takes paroxetine (Paxil) to treat posttraumatic stress disorder. The client states that he grinds his teeth during the night which causes pain in his mouth. The nurse should identify which of the following as possible measures to manage the client's bruxism? (Select all that apply.) A. Concurrent administration of buspirone B. Administration of a different SSRI C. Use of a mouth guard D. Changing to a different class of antianxiety medication E. Increasing the dose of paroxetine

A. Concurrent administration of buspirone C. Use of a mouth guard D. Changing to a different class of antianxiety medication

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 persons 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 assessing a client who is suicidal. Which of the following is appropriate for the nurse to ask the client? (Select all that apply.) A. Do you have a plan? B. Have you thought about hurting yourself? C. Do you feel that life is not worth living? D. Why do you want to commit suicide? E. Have you experienced a recent change in your mood?

A. Do you have a plan? B. Have you thought about hurting yourself? C. Do you feel that life is not worth living? E. Have you experienced a recent change in your mood?

A nurse is teaching an adolescent client who has a new prescription for clomipramine (Anafranil) for OCD. Which of the following should the nurse teach the client to minimize one of the adverse effects of his medication? A. Eat a diet high in fiber. B. Check temperature daily. C. Take medication first thing in the morning before eating. D. Add extra calories to the diet as between-meal snacks.

A. Eat a diet high in fiber. it is a TCA antidepressant

A nurse observes a client who is pacing and wringing his hands. The client states, "I don't know why, but I've worried every day for over a year that my son will die a horrible death." The nurse identifies that this finding is consistent with which of the following disorders? A. Generalized anxiety disorder B. Panic disorder C. Posttraumatic stress disorder D. Acute stress disorder

A. Generalized anxiety disorder

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following is an expected finding? (Select all that apply.) A. Hallucinations B. Obsessive need to talk about the traumatic event C. Exaggerated displays of emotion D. Recurring nightmares E. Diminished reflexes

A. Hallucinations D. Recurring nightmares

A pt tells the RN, "I was raped 8 years ago but never told anyone. Nevertheless, the memories haunt me everyday. I should be over it by now." Which comment should the RN offer next? A. It sounds like you're judging yourself for continuing to struggle w your reaction B. Rape is a criminal behavior. You should have reported the incident to law enforcement C. Are you now ready to engage in counseling to deal w your reactions to this experience? D. While it's important to learn from such life events, it's more important to put things in the past.

A. It sounds like you're judging yourself for continuing to struggle w your reaction

A nurse is making a home visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following are appropriate suggestions to decrease the client's risk for injury? (Select all that apply). A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the client's mattress on the floor. E. Install light fixtures above stairs

A. Install childproof door locks. D. Place the client's mattress on the floor. E. Install light fixtures above stairs

A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence grief and coping ability? (Select all that apply.) A. Interpersonal relationships B. Culture C. Birth order D. Size of family E. Prior experience with loss

A. Interpersonal relationships B. Culture E. Prior experience with loss

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are used to prevent a relapse of MDD."

A. "Care during the continuation phase focuses on treating continued manifestations of MDD." The focus of continuation phase is to prevent relapse. Acute phase is the tx of s/s

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine (Prozac). Which of the following findings should the nurse report to the provider as an indication of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

B. Hallucinations D. Diaphoresis E. Agitation

A nurse manager is discussing the care of a client 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 pt diagnosed with BPD lives in the community and is showing early signs of mania. The pt says, "I need to go visit my daughter but she lives across the country. I put some requests on the internet to get a ride. I'm sure someone will take me." What is the RN's most therapeutic response? A. "I'm concerned about your safety when meeting or riding with strangers." B. "Have you asked friends and family to donate money for your airfare?" C. "You are not likely to get a ride. Let's consider some other strategies." D. "Have you asked your daughter if she wants you to come for a visit?"

A. "I'm concerned about your safety when meeting or riding with strangers."

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client 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." clients who have avoidant personality disorder often have fear of abandonment

A patient at a general medical clinic tells the RN, "I have so many ailments that I need to see 6 different doctors. None of them has discovered what is really wrong with me." Which comment should be nurse offer next? A. "Let's review all the medications you currently take." B. "Tell me about allergic reactions you've had to medication." C. "Selecting one primary care provider would be better for you." D. "I'm not sure I understand how you can afford these expenses."

A. "Let's review all the medications you currently take." safety is the RN's first concern. One serious risk associated w doctor shopping is med interactions and duplicate meds.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

A. "Life isn't worth living if I gain weight."

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.) A. Amenorrhea B. Hypokalemia C. Mottling of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

B. Hypokalemia D. Slightly elevated body weight

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to this client? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?

A. "Stop screaming, and walk with me outside."

A community mental health RN counsels a group of pts about the upcoming flu season. What instruction does the RN provide for pts who are prescribed lithium? A. "Stop taking your medicine and contact me if you have nausea, vomiting, and or diarrhea." B. "Remember that lithium reduces your immunity, so you are more vulnerable to catching the flu." C. "The flu is contagious. Isolate yourself if you get the flu so that you avoid exposing others to it." D. "Because you take lithium you may have flu symptoms that are not typically experienced by others."

A. "Stop taking your medicine and contact me if you have nausea, vomiting, and or diarrhea."

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements by the nurse is appropriate? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

A. "Tell me about how you are feeling right now."

A charge nurse is discussing mirtazapine (Remeron) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I will need to monitor the client for hyponatremia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication.

A. "This medication increases the release of serotonin and norepinephrine."

A nurse is providing teaching to a client who has a new prescription for carbamazepine (Tegretol). Which of the following should the nurse include in the teaching? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

A. "This medication will help prevent seizures during alcohol withdrawal."

Which newly hospitalized pt should the RN monitor closely for development of delerium? A. 48 year old who usually drinks a six pack of beer daily B. 68 year old who takes aspirin 650 mg twice daily for arthritic pain C. 72 year old who says "I have a glass of wine every evening to stimulate my appetite." D. 78 year old diabetic whos blood glucose levels are consistently greater than 250 mg/dL

A. 48 year old who usually drinks a six pack of beer daily

Which scenario best demonstrates empathetic caring? A. A nurse provides comfort to a colleague after an error of medication administration. B. A nurse works a fourth extra shift in 1 week to maintain adequate staffing C. A nurse identifies a violation of confidentiality and makes a report to an agency's privacy offer D. A nurse conscientiously reads current literature to stay aware of new EBP.

A. A nurse provides comfort to a colleague after an error of medication administration.

A nurse is discussing routine follow-up needs for a client who has a new prescription for valproic acid (Depakote). The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium

A. AST/ALT and LDH

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the nurse notes that the lithium blood level is 1.2 mEq/L. Which of the following is an appropriate action by the nurse? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

A. Administer the next dose of lithium carbonate as scheduled.

A nurse is caring for an adult client who is the victim of intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of women's shelters. B. Encourage the client to participate in a support group for victims of abuse. C. Implement case management to coordinate community and social services. D. Educate the client about the use of stress management techniques

A. Advise the client about the location of women's shelters.

The parent of an adolescent recently diagnosed w schizophrenia says to the RN, "This is entirely my fault. I should have spent more time w my child when he was a toddler." Which response by the RN is correct? A. Schizophrenia is genetically transmitted, so it was not in your control B. Your childs disorder is more likely the result of an undetected head injury C. environmental toxins are directly implicated in the origins of schizophrenia D. Lack of prenatal care causes schizophrenia rather than early childhood events

A. Schizophrenia is genetically transmitted, so it was not in your control

A nurse is teaching the parents of a child with a new prescription for imipramine (Tofranil) and his parents about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Seizures B. Agitation C. Photophobia D. Dry mouth E. Irregular pulse

A. Seizures B. Agitation E. Irregular pulse these are all signs of TCA toxicity

A nurse is discussing silent rape reaction with a newly licensed nurse. Which of the following should the nurse identify as a characteristic of this type of reaction? (Select all that apply.) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. Unwillingness to discuss the sexual assault

A. Sudden development of phobias C. Increased level of anxiety during interview E. Unwillingness to discuss the sexual assault

A nurse is teaching a client who has a new prescription for imipramine (Tofranil) how to minimize anticholinergic effects. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Void just before taking the medication. B. Increase the dietary intake of potassium. C. Wear sunglasses when outside. D. Change positions slowly when getting up. E. Chew sugarless gum.

A. Void just before taking the medication. C. Wear sunglasses when outside. E. Chew sugarless gum.

A university football coach invites the campus RN to talk to the team about healthy relationships in the community. Which topic has priority for the RN to include? A. appropriate behavior w the intimate partners. B. University resources for counseling and support C. The importance of role modeling for children and teens D. Public recognition of children w life threatening illnesses

A. appropriate behavior w the intimate partners.

On the 6th anniversary of her spouses death a widow says "soemtimes life does not seem worth living anymore. I wish i could go to sleep and never wake up." Which response by the RN has priority? A. are you considering suicide? B. You still have so much to live for C. Grief can sometimes last for many years D. WHy do you continue to grieve something from long ago

A. are you considering suicide?

A Dr informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day the pt says to the RN, "My Dr said I have breathing problems, right?" Which nursing diagnosis is applicable? A. denial r/t acceptance of a new diagnosis B. chronic sorrow r/t unresolved life conflicts C. situational low self esteem r/t stress of new dx D. acute confusion r/t metatastic changes to cerebral fxn

A. denial r/t acceptance of a new diagnosis

A RN plans a psychoeducational group about physical health in an outpatient program for consumers dx w severe mental illness. Which topic has priority? A. heart healthy living B. living w diabetes C. ABCDEs of skin cancer D. breast and testicular self examination

A. heart healthy living

A pt who had a stroke 3 days ago tearfully tells the RN, "What's the use in living? im no good to anybody like this." Which action should the RN employ first when caring for a pt demonstrating hopelessness? A. implement the institutional protocol for suicide risk B. Support the pt to clarify and express feelings of grief C. Educate the pt about the success of stroke rehabilitation D. offer the pt an opportunity to confer w the pastoral counselor

A. implement the institutional protocol for suicide risk

16 years ago a toddler died in a tragic accident. Once a year the parents place flowers at the accident site. How would the RN characterize the parents behavior? A. mourning B. bereavement C. complicated grief D. disenfranchised grief

A. mourning

While entering the building of an elementary school RN observes a person in the distance emerging from a forest and approaching the school. The person is dressed in black from head to toe, wearing a backpack and carrying a long, narrow, dark object. Which action should the RN take first? A. move to a secure location B. observe the intruder's features C. Take note of the intruder's location D. Activate the school code for an intruder

A. move to a secure location

An ED RN talks with a newly admitted victim of reported rape. Which communication should the RN offer to comfort this pt? A. you are safe now. I will stay w you in this private room B. Would you like your friend to stay w you during your examination? C. You made a good decision to come to the hospital after you were raped D. What questions do you have about your examination by the SANE (sexual assault nurse examiner)

A. you are safe now. I will stay w you in this private room

A nurse is providing teaching to a client who has a new prescription for amitriptyline (Elavil). Which of the following client statements indicates understanding of the teaching? A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

B. "I may feel drowsy for a few weeks after starting this medication."

. A charge nurse is discussing transcranial magnetic stimulation (TMS) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "TMS is indicated for clients whose depression is not relieved by medication." B. "I will provide postanesthesia care following TMS." C. "TMS is usually performed as an outpatient procedure." D. "I will schedule the client for daily TMS treatments for the first several weeks."

B. "I will provide postanesthesia care following TMS."

A nurse is teaching a school-age child and his parents about a new prescription for lisdexamfetamine dimesylate (Vyvanse). Which of the following is appropriate for the nurse to include in the teaching? (Select all that apply). A. An adverse effect of this medication is CNS depression. B. Administer the medication right before breakfast. C. Monitor blood pressure while taking this medication. D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. E. This medication blocks the effects of dopamine in the brain.

B. Administer the medication right before breakfast. C. Monitor blood pressure while taking this medication.

A nurse is conducting a class for a group of newly licensed nurses on identifying risk factors for suicide. Which of the following individuals should the nurse include as having the highest risk for suicide? (Select all that apply.) A. Older adult females B. Adolescents C. Native Americans D. Clients who have a depressive disorder E. Clients who have hypomania

B. Adolescents C. Native Americans D. Clients who have a depressive disorder

A nurse is reviewing a newly admitted client's medical record. Which of the following documents is a directive for medical treatment based on the client's wishes? A. Advance directives B. Living will C. Informed consent D. Durable power of attorney for health care

B. Living will

A pt tells the RN, "after many years, I finally quit smoking. Now I use e-ciggs only." Which response should the RN provide? A. "Using e-ciggs is now more socially acceptable than using traditional ciggarettes." B. "COngratulations on quitting, but e-ciggs contain nicotine and other hazordorus chemicals." C. "Nicotine is a powerful addiction. Quitting smoking is a big step toward adopting a healthier lifestyle." D. "I am glad you quit smoking. Your loved ones will no longer be exposed to the hazards of second hand smoke."

B. "COngratulations on quitting, but e-ciggs contain nicotine and other hazordorus chemicals."

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior

B. Ask the client, "Are you seeing something on the ceiling?"

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following is an expected finding? (Select all that apply.) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

B. Substance use D. Irritability E. Aggressiveness

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."

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

B. "I am no one, and everyone is me."

An 84 year old tells the RN, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the RN should respond: A. "It is more important for you to have physical activity everyday." B. "Let's think of some other activities we can add to your daily routine ." C. "Repitition of the same activity is not helpful for keeping your brain healthy." D. "There are some herbal preparations that will also help keep your brain sharp."

B. "Let's think of some other activities we can add to your daily routine ."

A nurse is caring for a client who is on lithium therapy. The client 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."

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.) A. Lethargy B. Defensive responses to questions C. Disorientation D. Rapid breathing E. Facial grimacing F. Agitation

B. Defensive responses to questions D. Rapid breathing E. Facial grimacing F. Agitation

A nurse in an outpatient medical clinic talks to a pt w a long history of malingering and doctor-shopping. The pt continues to express complaints of multiple problems. Select the RN's best comment to the pt. A. "The treatment team believes you would benefit more from seeing a mental health professional." B. "The treatment team discussed your case and wants to begin a special case management program for you." C. "Because you take a number of medications, it would be safer to have them all filled at the same pharmacy." D. "Diagnostic testing has shown no medical problems and you are using more than your fair share of health care services."

B. "The treatment team discussed your case and wants to begin a special case management program for you."

A nurse is evaluating a client's understanding of a new prescription for clonidine (Catapres). Which of the following statements by the client 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 medicine." 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."

Which comment by a pt diagnosed with BPD best indicates that the pt is experiencing mania? A. "I have been sleeping about 6hrs each night." B. "Yesterday I made 487 posts on my social network page." C. "I am having dreams about my father's death 8 years ago." D. "My appetite is so robust that I've gained 4lbs in the past 2 weeks."

B. "Yesterday I made 487 posts on my social network page."

A nurse is caring for a client who has Alzheimer's disease and is beginning to experience noticeable short-term memory loss. When discussing a new prescription for donepezil (Aricept), the nurse should include which of the following in the teaching? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donepezil." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

B. "You can expect the progression of cognitive decline to slow with donepezil."

A charge nurse is reviewing Kübler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following should the charge nurse include in the teaching? (Select all that apply.) A. Endurance B. Denial C. Bargaining D. Anger E. Depression

B. Denial C. Bargaining D. Anger E. Depression

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

In which scenario is it most urgent for the nurse to act as a patient advocate? A. An adult cries and experiences anxiety after a near-miss automobile accident on the way to work. B. A homeless adult diagnosed with schizophrenia lives in a community expecting a category 5 hurricane. C. A 14-year-old girl's grades decline because she consistently focuses on her appearance and social networking. D. A parent allows the prescription to lapse for 1 day for their 8-year-old child's medication for ADHD.

B. A homeless adult diagnosed with schizophrenia lives in a community expecting a category 5 hurricane.

A parent tells the RN about the death of a child 2 years ago. Which comment by this parent warrants the RN's priority attention? A. i still have some of my child's toys and clothes B. A parent should never live longer than their child C. I never returned to church again after the death of my child D. My child has been dead a long time, but it seems like only yesterday.

B. A parent should never live longer than their child

Considering Maslow's pyramid, which comment indicates an individual is motivated by the highest level of need? A. Even though I'm 40 years old, I have returned to college so I can get a better job. B. I help my community by volunteering at a thrift shop that raises money for the poor." C. "I recently applied for a public assistance in order to feed my family, but I hope it's not forever." D. "My children tell me I'm a good parent. I feel happy being apart of a family that appreciates me."

B. I help my community by volunteering at a thrift shop that raises money for the poor."

A nurse working in an emergency department is caring for a client who has bezodiazepine toxicity due to an overdose. Which of the following is the priority nursing action? A. Administer flumazenil (Romazicon) B. Identify the client's level of orientation C. Infuse IV fluids D. Prepare the client for gastric lavage

B. Identify the client's level of orientation

3. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action? A. Respect the client's need for personal space. B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder

B. Identify the client's perception of her mental health status. Assessment is the priority action when taking the nursing process approach to client care. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take? A. Use therapeutic communication to discuss the hallucination with the client. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

B. Initiate one-to-one observation of the client.

An ED RN assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? A. leathery facial tone B. Injuries in the bikini pattern C. reluctance to be examined D. Lack of eye contact w the RN

B. Injuries in the bikini pattern

A nurse is preparing a community education seminar about family violence. When discussing the types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependant, even when funds are available, is neglect. B. Intentionally causing an older adult to fall is an example of physical violence. C. Striking an intimate partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse.

B. Intentionally causing an older adult to fall is an example of physical violence.

A pt in an ED was seen for the third time in a month w C/O tremors and paresthesia in the lower extremities. Conversion disorder was diagnosed. While preparing for discharge, the patient says, "Now I'm having chest pain but it's probably nothing." How should the nurse respond? A. Assess the pt's most current labs B. Interrupt the dx and arrange additional medical evaluation of the pt C. Remind the pt, "THe diagnostic tests showed you did not have a medical problem." D. Tell the pt, "Being in the ED a long time can be very distressing."

B. Interrupt the dx and arrange additional medical evaluation of the pt Despite the dx, the pts complaints need to be taken seriously. Further evaluation is needed.

A client says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

B. Lethality of the method and availability of means

An RN leads a milieu meeting in an outpatient program for adults dx w serious mental illness. Four consumers complain that another consumer is "always begging us for money." Which comment by the RN is therapeutic? A. If you can afford to help eachother, it is reasonable to do so B. Lets review what we have learned about being assertive with others C. No one needs to bring money to our program. Lunch is provided at no charge D. Lets show understanding of eachother. Money management is a problem for everyone.

B. Lets review what we have learned about being assertive with others

A woman in a relationship characterized by a long hx of battering and abuse tells the RN, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." WHich event would the RN expect to occur next in this relationship?" A. Another beating by the abusive partner B. Love, gifts, and praise by the abusive partner C. A brief period during which the partners ignore each other D. The abusive partner leaves the relationship for a short time

B. Love, gifts, and praise by the abusive partner

A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following would be an example of client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

B. Marriage

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication

B. Offer concise explanations C. Establish consistent limits E. Use a firm approach with communication

A nurse is caring for a client who is taking phenelzine (Nardil). For which of the following adverse effects should the nurse observe? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism

B. Orthostatic hypotension D. Headache

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (Select all that apply.) A. Lithium carbonate (Lithobid) B. Paroxetine (Paxil) C. Risperidone (Risperdal) D. Haloperidol (Haldol) E. Lorazepam (Ativan)

B. Paroxetine (Paxil) E. Lorazepam (Ativan)

A nurse is discussing early indications of toxicity with a client 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

An outpatient RN has lunch w a group of consumers dx w severe mental illness. The RN observes an obese adult ask a malnourished adult, "If you aren't going to eat your apple, will you give it to me?" What is the RN's best action? A. remind both adults that sharing food w eachother is not permitted B. Remind the malnourished adult of tx goals r/t wt gain C. reseat the consumers at two seperate tables for the remainder of the meal D. Overlook the remark. Both adults are permitted to make their own decisions.

B. Remind the malnourished adult of tx goals r/t wt gain

A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following indications should the nurse assess? A. Impulsive behavior B. Repetitive counting C. Destructiveness D. Somatic problems

B. Repetitive counting

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 that 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 preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply.) A. Sunken fontanelles B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. An increase in head circumference

B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. An increase in head circumference

A nurse working in an emergency department is assessing a child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply.) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

B. Round burn marks on forearms E. Areas of ecchymosis on torso

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

An RN who has worked for a community hospice organization for 8 years says, "My pts and their families experience overwhelming suffering. No matter how much I do, it's never enough." which problem should the RN supervisor suspect? A. The RN is experiencing spiritual distress B. THe RN is at risk for burn out and compassion fatigue C. The RN is not recieving adequate recognition from others D. THe RN is at risk for overhelping, which creates dependency.

B. THe RN is at risk for burn out and compassion fatigue

An RN plans to lead a group in a residential facility for kindergarten -aged, abused children. Which strategy should the RN incorporate? A. building a house using blocks B. Telling a story about a child who felt sad C. Drawing pictures of fun activities at a park D. Reading and discussing a book about abused children

B. Telling a story about a child who felt sad

A woman experienced a double mastectomy yesterday. Now she cheerfully says to the RN, "I didn't need those things anyways. No more wet T-shirt contests for me!" How should the RN interpret this comment? A. The pt is realistically accepting her loss B. The comment is sarcastic, which may reflect anger C. The pt is experiencing a distorted body image D. The comment suggests guilt regarding prior behavior

B. The comment is sarcastic, which may reflect anger sarcasm is a veiled form of anger

An ED RN assesses a child w a fractured ulna. The RN also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the RN to consider making a report to CPS? A. We do not believe in immunizations of our children B. This child is always creating problems for our family C. Our child would rather play alone than with other children D. We homeschool our children in order to include religious education

B. This child is always creating problems for our family

The RN in a HS meets with small groups of students the day after a school bus accident resulted in the death of 5 students. Which comment should the RN use to begin the session?" A. Sometimes life is not fair. Yesterdays tragedy is an example of how unfair it can be. B. We're grateful that you are safe. Our discussion is to talk about feelings associated with yesterdays tragedy. C. We've had a terrible loss. I also feel your pain. You need to talk about your feelings associated with the event. D. Thank you for coming today. As school leaders, we know it is very important to respond to yesterday's tragedy.

B. We're grateful that you are safe. Our discussion is to talk about feelings associated with yesterdays tragedy.

A nurse is providing teaching to an adolescent who is to begin taking atomoxetine (Strattera) for ADHD. The nurse should instruct the client to monitor for and report which of the following indications of liver damage? (Select all that apply). A. Mood changes B. Yellowing skin C. Joint pain D. Fever E. Malaise

B. Yellowing skin D. Fever E. Malaise

Which scenario presents the highest risk for a pregnancy resulting in offspring w an intellectual developmental disability (IDD)? A. an 18 y/o mother who recieved no prenatal care B. a 32 y/o mother dx w anorexia nervosa C. a 26 y/o father w a hx of episodic alcohol abuse D. a 38 y/o father dx w GAD

B. a 32 y/o mother dx w anorexia nervosa

a nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (act) group? a. a client in an acute care mental health facility who has fallen several times while running down the hallway B. a client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia c. a client in a day treatment program who says he is becoming more anxious during group therapy D. a client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months

B. a client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia

A nurse decides to put a client who has psychosis in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. This is an example of A. beneficence. B. a tort. C. a facility policy. D. justice

B. a tort. A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment.

a nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply.) a. encourage the group to work toward goals. B. define the purpose of the group. C. discuss termination of the group. d. identify informal roles of members within the group. e. establish an expectation of confidentiality within the group.

B. define the purpose of the group. C. discuss termination of the group. e. establish an expectation of confidentiality within the group.

A person dx w severe mental illness has been homeless for 8 years and says, "I don't have any money bc I've never had a job. I can't afford a place to live." Which intervention should the outpatient mental health nurse add to the plan of care? A. requisition the pts legal record of arrests and convictions B. help the pt apply for supplemental security income (SSI) C. assist the pt to apply for social security disability income (SSDI) D. Seek to have the pt adjudicated non compos mentis (incompetent)

B. help the pt apply for supplemental security income (SSI)

An 85 y/o woman says to the RN, "I raised three children, but now 2 of them barely speak to me. I did not do a good job of instilling a family spirit." Which response should the nurse provide? A. do you think this situation is likely to change? B. if you could relive those earlier years, what would you do differently? C. There's no guidebook for parenting. Your children have made their own choices D. Your children are likely to regret their behavior. I hope you can find it in your heart to forgive them.

B. if you could relive those earlier years, what would you do differently?

a nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following? a. placation B. manipulation C. Blaming d. distraction

B. manipulation

A pt diagnosed w MDD was hospitalized for 2 weeks on an acute psychiatric unit. One day after discharge, the pt completed suicide. Recognizing likely reactions among staff, which action should the nursing supervisor implement first? A. assess each staff member individually for suicidal intent and/or plans B. provide a private setting for staff members to talk about feelings associated w the event C. remind staff members that suicide is a risk for the pt population and they are not at fault D. Invite a guest speaker to conduct an educational session for staff about suicide risk factors

B. provide a private setting for staff members to talk about feelings associated w the event

Friends invite an adult diagnosed with DMII to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty w blood glucose management during strenuous activity. Which defense mechanism is evident? A. displacement B. rationalization C. passive aggression D. reaction formation

B. rationalization

A 92 y/o lives alone but family members assist w transportation and home maintenence. THis adult tells the RN, "They mean well but sometimes my family treats me like a child." What is the RN's best action? A. Encourage the adult to overlook these behaviors from family members B. role play w the adult ways to share feelings w family members C. contact family members privately and educate them about the harmful effects of ageism D. reinforce family members good intentions and say, "its fortunate your family is so helpful."

B. role play w the adult ways to share feelings w family members

The RN asks an 87 y/o "how are you doing?" the pt replies, "I have good days and bad days." Select the RN's therapeutic response A. How is your sleep B. tell me more about that C. are you feeling depressed D. we expect that from people your age

B. tell me more about that

a nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? a."even if my anxiety improves, i will need to continue this therapy for 6 weeks." B."the therapist will focus on my past relationships during our sessions." c."Psychoanalysis will help me reduce my anxiety by changing my behaviors." d."this therapy will address my conscious feelings about stressful experiences."

B."the therapist will focus on my past relationships during our sessions."

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply.) A.Chronic pain B.Depressed immune system C.Increased blood pressure D.Panic attacks e.Unhappiness

B.Depressed immune system C.Increased blood pressure e.Unhappiness

A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A.Learn to practice mindfulness. B.Use assertiveness techniques. C. exercise regularly. D. rely on the support of a close friend.

B.Use assertiveness techniques.

A group of nurses privately discuss patients under their care. Which nurse's comment indicates the need for clinical supervision regarding countertransference? A. "My patient is always asking my permission to do something just like a child." B. "When our unit is understaffed, it seems like we have more incidents of disruptive behavior." C. "My patient tries to tell me what to do all the time. I got a divorce because my spouse used to do that." D. "Our patients have had so many traumatic life experiences. I find myself feeling sympathetic sometimes."

C. "My patient tries to tell me what to do all the time. I got a divorce because my spouse used to do that."

A RN teaches a pt diagnosed w an alcohol addiction about a new RX for naltrexone (ReVia, VIvitrol). Which comment by the pt indicates the teaching was effective? A. "THis medicine will stop my cravings for alcohol." B. "I should take this medication only when I feel cravings to drink alcohol." C. "This medication is one part of a bigger treatment plan to help me stay sober." D. "I should not use products that contain alcohol, such as cough medicine and after shave lotion."

C. "This medication is one part of a bigger treatment plan to help me stay sober."

An RN begins a theraputic relationship w a pt diagnosed w schizophrenia. The pt has severe paranoia. Which comment by the RN is most appropriate? A. "Let's begin by talking about the goals that you have for yourself" B. "I understand that you have probs w fear and suspiciousness of others" C. "As you get to know me better, I hope you will feel comfortable talking to me" D. "I am part of your treatment team. Our goal is to help stabilize your symptoms"

C. "As you get to know me better, I hope you will feel comfortable talking to me"

A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysthymic disorder

C. Bipolar disorder with rapid cycling

An adult plans to attend an upcoming tenth high school reunion. This person says to the nurse, "I am embarassed to go. I will not look as good as my classmates. I haven't been successful in my career." Which comment by the nurse addresses this cognitive distortion? A. "You look fine to me. Do you think you will have fun at your reunion?" B. "Everyone ages. Other classmates have had more problems than you." C. "Do you think you are the only person who has aged and faced difficulties in life?" D. "I think you are doing well in the face of the numerous problems you have endured."

C. "Do you think you are the only person who has aged and faced difficulties in life?"

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 relapse of bipolar disorder."

C. "ECT is effective for clients who are experiencing severe mania."

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates a need for further teaching? A. "A criminal history increases the risk for violence between strangers." B. "Substance use disorder increases the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence toward the intimate partner."

C. "Entering an intimate relationship increases the risk for violence."

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

C. "I am aware that my PMDD causes me to have rapid mood swings."

The nurse interacts with a veteran of WWII. The veteran says, "Veterans of modern wars whine and complain all the time. Back when I was in service, you kept your feelings to yourself." Select the nurse's best response. A. "American society in the 1940s expected WWII soliders to be strong." B. "WWII was fought in a traditional way but the enemy is more difficult to identify in today's wars." C. "We now have a better understanding of how trauma effects people and the importance of research-based, compassionate care." D. "Intermittent explosive devices (IEDs), which were not in use during WWII, produce traumatic brain injuries that must be treated."

C. "We now have a better understanding of how trauma effects people and the importance of research-based, compassionate care."

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements indicates the need for further teaching? A. "I will administer prophylactic treatment for sexually transmitted infections like chlamydia." B. "I need to obtain informed consent before the sexual assault nurse examiner obtains forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should perform a self-assessment before caring for a client who has been raped."

C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder."

A patient diagnosed w dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff RN's comment should prompt the nursing supervisor to intervene? A. "I have never taken care of a pt w this disorder." B. "I think this pt was misdiagnosed and probably has schizophrenia." C. "I find myself more fascinated and engaged with this patient than others." D. "I recently read an autobiographical book about someone with this problem."

C. "I find myself more fascinated and engaged with this patient than others."

A nurse is caring for a client who lost his mother to cancer last month. Which of the following statements made by the nurse is a nontherapeutic response? A. "You sound angry." Anger is a normal feeling associated with loss." B. "Tell me more about your how you are feeling." C. "I understand just how you feel. I felt the same when my mother died." D. "Let's discuss how you have been coping."

C. "I understand just how you feel. I felt the same when my mother died."

A nurse is caring for a client who has bulimia nervosa and who has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following is an appropriate response by the nurse? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone (Fanapt). Which of the following client statements indicates understanding of the teaching? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

C. "I will be careful not to gain too much weight while taking this medication."

A nurse is caring for a client who is to begin taking fluoxetine (Prozac) for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet while taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."

C. "I will need to discontinue this medication slowly."

A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? A. "I look good because whenever I overeat, I purge myself." B. "I love sweets. I make myself throw up so I can eat more." C. "I've lost 60 lbs but I'm still a size 2. I want to be a size 0." D. "I've hidden my eating disorder from everyone, even my parents."

C. "I've lost 60 lbs but I'm still a size 2. I want to be a size 0."

A pt tells the community mental health RN, "I told my HCP I was having trouble sleeping and he prescribed me trazodone 50 mg qnight. I read on the internet that RX is an antidepressant, but I'm not depressed. What should I do?" Which response by the RN is correct? A. "I will help you contact your HCP for clarification regarding the new RX." B. "Insomnia and depression usually go hand in hand. If your depression is relieved, your sleep will improve." C. "In low doses, trazodone helps relieve insomnia. Higher doses are needed for antidepressant effects to occur." D. "Information on the internet is often misleading and incorrect. It's more important to trust the judgement of your HCP."

C. "In low doses, trazodone helps relieve insomnia. Higher doses are needed for antidepressant effects to occur."

The nurse assesses a new patient suspected of having a schizotypal personality disorder. Which assessment question is this patient most likely to answer affirmatively? A. "Do some types of situations frighten you?" B. "Do you often have episodes of prolonged crying?" C. "Is anyone in your family diagnosed with a mental illness?" D. "Is it ever very important for you to do everything correctly?"

C. "Is anyone in your family diagnosed with a mental illness?" Genetics seem to play an important role in the development of schizotypal personality disorder. It is more common in fams w hx of schizophrenia.

A pt begins a new rx for risperidone (Risperidal). Which intervention should the nurse include in the plan of care? A. Monitor I&O daily B. Educate pt about tyramine containing foods C. Assess sitting, standing, and lying B/P daily D. Administer w food to reduce GI irritation

C. Assess sitting, standing, and lying B/P daily

An adult has had long term serious medical problems resulting in decreased libido and sexual preformance. The adult's spouse privately says to the nurse, "I don't feel loved anymore. I feel sexual urges but my partner is not interested." Select the RN's theraputic response. A. "Tell me about how your partner shows love to you." B. "You're describing a scenario that many couples face." C. "Let's consider some other ways you can satisfy your needs." D. "I'm glad you're able to talk about and accept your situation."

C. "Let's consider some other ways you can satisfy your needs."

A pt experiencing depression says to the RN, "My health care provider said I need 'talk therapy' but I think i need RX for antidepressant medication. What should I do?" Select the RN's best response. A. "Which antidepressant medication do you think would be helpful?" B. "There are different types of talk therapy. Many patients find it beneficial." C. "Let's consider some ways to address your concerns with your HCP." D. "Are you willing to give 'talk therapy' a try before starting an antidepressant medication?"

C. "Let's consider some ways to address your concerns with your HCP." Helping pt to advocate for self is empowering and will help to decrease helplessness (a symptom of depression).

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C. Attempt to reduce anxiety

A nurse is providing teaching to the family of a client 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 Al-Anon group to help her recover." D. "The primary goal of her treatment is abstinence from substance use."

C. "She should participate in an Al-Anon group to help her recover." Al-Anon is for the fam, AA is for the pt.

Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? A. "You need to gain weight to become healthier." B. "Your world would not change if you gained a few pounds." C. "Tell me how your world would be different if you were fat." D. "Your attractiveness is not defined by a number on the scale."

C. "Tell me how your world would be different if you were fat."

A family member asks the RN, "I know my uncle's Alzehimer's disease has progressed but is there any medication that can help him now?" Which response by the nurse is correct? A. "I'm sorry, but there are no medications that help with severe Alzheimer's." B. "Alzheimer's sometimes stabilizes. Let's hope that happens in this situation." C. "There are a few medications that may help. Let's discuss it with the HCP." D. "It sounds like your'e having difficulty accepting that your uncle's disease is irreversible. WOuld you like to talk about those feelings."

C. "There are a few medications that may help. Let's discuss it with the HCP."

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following is an appropriate response by the nurse? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do feel that you should not have been alone on the street at night?"

C. "You believe this wouldn't have happened if you hadn't been out alone?"

After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder? A. "These sandwiches are probably contaminated with bacteria." B. "I suppose it's the best we can hope for under these circumstances." C. "You should have ordered a to-go meal from a local restaurant for me." D. "I would rather wait to eat until the dietary department can prepare a meal."

C. "You should have ordered a to-go meal from a local restaurant for me."

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this 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 other 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 other clients to give him their belongings E. Blames others for his past and current problems

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum (Nicorette). Which of the following is appropriate to include in the teaching? A. Chew the gum for no more than 10 min. B. Rinse out the mouth immediately before chewing the gum. C. Avoid eating 15 min prior to chewing the gum. D. Use of the gum is limited to 90 days.

C. Avoid eating 15 min prior to chewing the gum.

Which scenario presents the most risk factors for suicide? A. 64 y/o black female whose husband died 3 years ago B. 72 y/o white female scheduled for hip replacement in 2 weeks C. 82 y/o widowed white male recently dx w pancreatic cancer D. 92 y/o black male who recently moved into the home of his adult children

C. 82 y/o widowed white male recently dx w pancreatic cancer

Which of the following is an example of a client who requires emergency admission to a mental health facility? A. A client with schizophrenia who has frequent hallucinations B. A client with symptoms of depression who attempted suicide a year ago C. A client with borderline personality disorder who assaulted a homeless man with a metal rod D. A client with bipolar disorder who paces quickly down the sidewalk while talking to himself

C. A client with borderline personality disorder who assaulted a homeless man with a metal rod

Which patient is liekely to acheive maximum benefit from Cognitive Behavioral Therapy (CBT)? A. older adult diagnosed with stage 3 alzheimer's disease B. Adult diagnosed with schizophrenia and experiencing delusions C. Adult experiencing feelings of failure after losing the fourth job in 2 years D. School-age child diagnosed with attention-deficit/hyperactivity disorder (ADHD)

C. Adult experiencing feelings of failure after losing the fourth job in 2 years

Select the best example of altruism. A. After recovering from open a GSW, a police officer attends a local support group. B. After recovering from open heart surgery, an individual plays tennis three times a week. C. An individual who received a liver transplant volunteers at a local organ procurement agency. D. An individual w a long - standing fear of animals volunteers at a community animal shelter.

C. An individual who received a liver transplant volunteers at a local organ procurement agency.

A nurse is caring for a client who takes ziprasidone (Geodon). The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (Select all that apply.) A. Olanzapine (Zyprexa) B. Quetiapine (Seroquel) C. Aripiprazole (Abilify) D. Clozapine (Clozaril) E. Paliperidone (Invega)

C. Aripiprazole (Abilify) D. Clozapine (Clozaril)

A pt has a long hx of BPD w frequent episodes of mania secondary to stopping prescribed meds. The pt says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the RN's best actions. A. Educate the pt about how the low odds of winning the lottery. B. Present reality by saying to the pt, "That's not a good use of your money." C. Confer with the treatment team about appointing a legal guardian for the pt. D. Tell the pt, "If you buy lottery tickets, your money will run out before the end of next month."

C. Confer with the treatment team about appointing a legal guardian for the pt.

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.) A. Allow the child to choose consequences for negative behavior. B. Use role playing to act out unacceptable behavior. C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long-term abstinence from alcohol? (Select all that apply.) A. Lorazepam (Ativan) B. Diazepam (Valium) C. Disulfiram (Antabuse) D. Naltrexone (Vivitrol) E. Acamprosate (Campral)

C. Disulfiram (Antabuse) aversion D. Naltrexone (Vivitrol) suppresses cravings and pleasurable effects E. Acamprosate (Campral) decreases unpleasant effects from abstinence

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide (Librium) B. Bupropion (Zyban) C. Disulfiram (Antuse) D. Carbamazepine (Tegretol)

C. Disulfiram (Antuse)

select the completion of this statement that demonstrates an adult is coping in a healthy way. "I am feeling so angry right now,...." A. Im afraid im going to cry B. I would like to punch something C. I want to talk to someone about it D. I want to curl up and sleep for a long time

C. I want to talk to someone about it

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following is the priority nursing intervention? A. Orient the client 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 young adult tells the RN, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the RN provide first to the pt? A. Guidence that the RX should not be shared w peers B. Directions to weigh self once a week and maintain a log of the results C. Instructions about safety issues associated w driving or operating machinery D. Info about the potential amotivational syndrome and memory problems

C. Instructions about safety issues associated w driving or operating machinery

An ED RN prepares to discharge a victim of reported rape. Which comment by the victim indicates that the nurse's teaching was effective? A. I should bathe frequently over the next week B. I am required to follow up w law enforcement C. Its important for me to follow up w counseling D. I should delay any sexual activity for at least 3 mos

C. Its important for me to follow up w counseling

a nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions? a. observes group techniques without interfering with the group process B. discusses a technique and then directs members to practice the technique C. asks for group suggestions of techniques and then supports discussion d. Suggests techniques and asks group members to reflect on their use

C. asks for group suggestions of techniques and then supports discussion

A nurse is conducting therapy with a several clients and their families. Effective communication with clients and families is based on A. discussing in-depth topics with which the client feels comfortable. B. using silence to avoid unpleasant or difficult topics. C. attending to verbal and nonverbal behaviors. D. requiring the client and family to ask for feedback.

C. attending to verbal and nonverbal behaviors.

The RN at a local medical clinic reviews phoned-in requests from patients for prescription refills. As the RN confers with the HCP about which RX refill requests should be authorized, Which refill request should be considered first? A. Codiene 10 mg PO q4h PRN for adult with a persistent cough B. Hydroxizine (Vistaril) 25 mg po TID PRN for an adult who experiences uncomfortable muscle spasms C. Lorazepam (Ativan) 1 mg PO BID for an a dult who has taken it daily for 3 years for episodes of anxiety. D. Paregoric (canphorated tincture of opium) 2 mg PO q6h PRN for an adult experiencing extreme diarrhea.

C. Lorazepam (Ativan) 1 mg PO BID for an a dult who has taken it daily for 3 years for episodes of anxiety.

The RN at a local medical clinic reviews phoned in requests from pts for RX refills. As the RN confers w the HCP about which prescription refill requests should be authorized, which refill request should be considered first? A. Codiene 10 mg PO q5h PRN for an adult w persistent cough B. Hydroxizine (Vistaril) 25 mg po TID PRN for an adult who experiences uncomfortable muscle spasms C. Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for anxiety. D. Paregoric (camphorated tincture of opium) 2 mg PO q6h PRN for an adult experiencing severe diarrhea.

C. Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for anxiety.

A nurse is assessing a client immediately following an electroconvulsive therapy (ECT) procedure. Which of the following are expected findings? (Select all that apply.) A. Hypotension B. Paralytic ileus C. Memory loss D. Nausea E. Tachycardia

C. Memory loss D. Nausea E. Tachycardia

The RN cares for a hospitalized adolescent diagnosed with MDD. The HCP provides a low-dose antidepressant. In consideration of published warnings about use of antidepressant medications in younger patients, which action should the nurse employ? A. Notify the facility's patient advocate about the new RX. B. Teach the adolescent about black box warnings associated with antidepressant medications. C. Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior. D. Remind the HCP about warnings associated with the use of antidepressants in children or adolescents.

C. Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings. B. Maintain eye contact with the client. 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.

While weighing pts on an eating disorder unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? A. Report the clinical observation to the nursing supervisor. B. Ask the psychiatric tech, "What did you mean by that comment?" C. Privately discuss the importance of sensitivity with the psychiatric tech D. Immediately interrupt the interaction between the pt and psychiatric technician.

C. Privately discuss the importance of sensitivity with the psychiatric tech

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's spouse, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following is an appropriate action by the nurse? A. Verify that a current power of attorney document is on file. B. Instruct the client's spouse to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

C. Provide information on resources for respite care.

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications? A. Chlorpromazine (Thorazine) B. Thiothixene (Navane) C. Risperidone (Risperdal) D. Haloperidol (Haldol)

C. Risperidone (Risperdal)

A nurse assesses a client at a community mental health facility using the SAD PERSONS tool. The nurse knows that this tool provides which of the following data related to a client? A. Current anxiety level B. Problem-solving ability C. Suicide potential D. Mood disturbance

C. Suicide potential

A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. D. Report the incident, but do not inform the client of the intention to do so.

C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. This is a serious safety issue that must be reported to the staff. Using the principle of veracity, the student tells this client truthfully what must be done regarding the issue.

A nurse is reviewing the medical record of a client 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 client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained a head injury. D. The client has a BMI of 25 and has gained 10 lb over the last year.

C. The client had a motor vehicle crash last year and sustained a head injury.

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect? A. There are wide fluctuations in mood. B. The report of a minimum of five clinical findings of depression. C. The presence of manifestations for at least 2 years. D. There is an inflated sense of self-esteem.

C. The presence of manifestations for at least 2 years.

While interacting with a 62 year old adult diagnosed with a progressive neurocognitive disorder, the RN observes that the adult has slow responses and difficulty finding the right words. What is the RN's best initial action? A. Suggest words that the adult may be trying to remember. B. Ask the adult, "are you having problems saying what you mean?" C. Use the silence to allow the adult the opportunity to compose responses. D. Discontinue the interaction to prevent further frustration for the adult.

C. Use the silence to allow the adult the opportunity to compose responses.

a nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? a. a member who praises input from other members B. a member who follows the direction of other members C. a member who brags about accomplishments d. a member who evaluates the group's performance toward a standard

C. a member who brags about accomplishments

A nurse participating in a community health fair interviews an adult who has had no interaction with a health care professional for more than 10 years. The adult says, "I like to keep to myself. Crowds make me nervous." Which action should the nurse employ? A. Refer the adult for a full health assessment. B. Explore the adults fam and social relationships C. ask the adult, "how do you feel about the quality of your life?" D. Explain to the adult, "We can help you feel better about yourself.

C. ask the adult, "how do you feel about the quality of your life?"

An 8 year old tells a parent, "I like to scare kids at school by showing them pictures of clowns. Some kids are terrified." How should the RN conusel the parents regarding this behavior? A. Recommend family therapy for the child, siblings, and parents B. Suggest the parents enroll the child in an anger management program C. educate both parents about bullying, including the long term effects and possible origins D. Teach the parents about the developmental phase and tasks for an 8 year old child

C. educate both parents about bullying, including the long term effects and possible origins

A 28 y/o second grade teacher is dx with MDD. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 y/o. Which combination of fx in this scenario best demonstrates the stress-diathesis model? A. Cold climate coupled with hx of abuse B. Current age of 28 coupled w fam hx of depression C. fam hx of mental illness coupled with hx of abuse D. female gender coupled with stressful profession of teaching

C. fam hx of mental illness coupled with hx of abuse The stress diathesis model explains depression from an environmental, interpersonal, and life events perspective combined w biological vulnerability or predisposition (diathesis). Psychosocial stressors and interpersonal events, such as abuse, trigger certain neurophysical and neurochemical changes in the brain. Early life trauma is a significant component in the stress reaction.

a charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply.) a. the needs of both participants are met. B. an emotional commitment exists between the participants. C. it is goal-directed. d. Behavioral change is encouraged. e. a termination date is established.

C. it is goal-directed. d. Behavioral change is encouraged. e. a termination date is established.

In a hostile voice, a pt experiencing mania yells at the nurse: "you will listen to me and not interrupt. I have some really important stuff to say. I'm tired of you RNs and DRs acting like you have all the answers." To facilitate effective communication, which initial response should the RN provide? A. you are our pt, so we always listen to you B. i can talk w you better if you use a calm voice C. its our job to help you get through this manic phase D. pts have an important role in treatment planning

C. its our job to help you get through this manic phase ((The book says this but I thought it was B. i can talk w you better if you use a calm voice .... the explanation in the book suggests the correct answer suggests an appropriate behavior so I think this is accurate))

an RN working in the county jail assesses four new inmates. The RN should direct gaurds to place which inmate under suicide watch? An inmate charged w: A. breaking and entering B. criminal solicitation C. lewd and lascivious (sexual) act on a minor D. assault and battery on an elderly person

C. lewd and lascivious (sexual) act on a minor

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply.) A. hypotension B. paralytic ileus C. memory loss D. nausea E.Confusion

C. memory loss D. nausea E.Confusion

THe RN interviews the parent of a 7 year old child diagnosed w moderate autism spectrum disorder. Which comment from the parent best describes autistic behavior? A. my child occasionally has temper tantrums B. sometimes my child wakes up with nightmares C. my child swings for hrs on our backyard gym set D. toilet training was more difficult for this child than my other children

C. my child swings for hrs on our backyard gym set

Three days after beginning a regimen of haloperidol (Haldol) 10 mg BID, the RN observes that a hospitalized pt is drooling, has stiff and extended extremities, and has skin that is damp and hot to touch. The pt has difficulty responding verbally to the RN. What is the RN's correct analysis and action in the situation? A. A seizure is occuring; place pt in lateral recumbant position and monitor B. serotonin syndrome has developed; place an IV line and rapidly infuse D51/2NS C. neruoleptic malignant syndrome has developed; prepare the pt for immediate transfer to a medical unit. D. an acute dystonic reaction is occuring; promptly administer an IM injection of diphenhydramine (Benadryl).

C. neruoleptic malignant syndrome has developed; prepare the pt for immediate transfer to a medical unit.

An elderly widow tells the RN, "Since my sister in laws death, her husband has been making advances at me. He tried to come in my home w a bottle of wine. Even though he's family, I'm afraid of what might happen if I let him in." Which action should the RN take first? A. Support the widow to clarify her thoughts and feelings about the situation B. explain to the widow how to obtain an order of protection (restraining order) C. positively reinforce the widow for addressing the problem w a caring professional D. Educate the widow about sexual assault and violence, including the importance of prevention

C. positively reinforce the widow for addressing the problem w a caring professional

a nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? a."i feel very sorry for the loneliness you must be experiencing." B."Suicide is not the appropriate way to cope with loss." C."Losing someone close to you must be very upsetting." d."i know how difficult it is to lose a loved one."

C."Losing someone close to you must be very upsetting."

a nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? a."You and a group of other clients will meet to discuss your treatment plans." B."Community meetings have a specific agenda that is established by staff." C."You and the other clients will meet with staff to discuss common problems." d."Community meetings are an excellent opportunity to explore your personal mental health issues."

C."You and the other clients will meet with staff to discuss common problems."

A nurse is leading a peer group discussion about the indications for ECt. Which of the following indications should the nurse include in the discussion? A.Borderline personality disorder B. acute withdrawal related to a substance use disorder C.Bipolar disorder with rapid cycling D.Dysphoric disorder

C.Bipolar disorder with rapid cycling

Which comment by the nurse would be appropriate to begin a new nurse- patient relationship? A. "Which of your problems is most serious?" B "I want you to tell me about your problems" C "I'm an experienced nurse, you can trust me." D "What would you like to tell me about yourself?"

D "What would you like to tell me about yourself?"

A young adult has heavily abused alcohol and prescription drugs since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the RN presents reality while demonstrating compassion? A. "I know you must feel self conscious about using a cane at your age, but it will help prevent falls." B. "Addiction is a fatal disease. If you continue to drink like you have done in the past, you will not live another 10 years." C. "It's time to face your addiction. You are disappointing your family and must stop drinking for the sake of the people who love you." D. "Addiction is powerful. You are young yet cannot walk without a cane. If you don't make changes your health will continue to suffer."

D. "Addiction is powerful. You are young yet cannot walk without a cane. If you don't make changes your health will continue to suffer."

A nurse working in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching? A. "Behaviors associated with ADHD must be present prior to age 3." B. "This disorder is characterized by argumentativeness." C. "Below-average intellectual functioning is associated with ADHD." D. "Because of this disorder, your child is at an increased risk for injury."

D. "Because of this disorder, your child is at an increased risk for injury."

Over the past 2 mos a pt made 8 suicide attempts w increasing lethality. The HCP informs the pt and family that ECT is needed. The family whispers, "isn't this a dangerous treatment?" How should the nurse reply? A. "Our facility has an excellent record of safety associated w use of ECT." B. "Your fam member will eventually be successful w suicide if aggressive measures are not promptly taken." C. "Yes, there are hazzards w ECT. You should discuss those concerns with your HCP." D. "ECT is ver effective when urgent help is needed. Your family member was carefully evaluated for potential risks."

D. "ECT is ver effective when urgent help is needed. Your family member was carefully evaluated for potential risks."

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. "Assign the client to a private room." B. "Document the client's behavior every hour." C. "Allow the client to keep perfume in her room." D. "Ensure that the client swallows medication."

D. "Ensure that the client swallows medication."

A nurse in a long-term care facility is caring for a resident who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following is an appropriate response by the nurse? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

D. "I am your nurse. Let's walk together to your room." It is important for the nurse to introduce herself with each new interaction, and to promote reality in a calm, reassuring manner.

The RN assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the RN to seek guidance? A. "Sometimes I get so discouraged and frustrated with my job." B. "It's incredible that anyone could hurt a child or a elderly person." C. "THe abuser was probably a victim of abuse at some point in life." D. "I hope the abuser gets victimized so they know what it feels like."

D. "I hope the abuser gets victimized so they know what it feels like."

When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."

D. "I understand you're concerned. Let's discuss what concerns you specifically." A therapeutic response reflects upon, and accepts, the family's feelings, and it allows the members to clarify what they are feeling.

A nurse is providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I will have seizures lasting 1½ to 2 min during ECT." D. "I will receive a muscle relaxant to protect me from injury during ECT."

D. "I will receive a muscle relaxant to protect me from injury during ECT."

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'd better listen to me."

D. "You'd better listen to me."

A nurse is discussing normal uncomplicated grief with a client who recently lost a child. Which of the following statements made by the client requires additional intervention? A. "I may experience feelings of resentment." B. "I may withdraw from others." C. "It is possible to experience changes in sleep." D. "It is possible to experience suicidal thoughts."

D. "It is possible to experience suicidal thoughts."

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 client's opioid 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 client's risk for acetaldehyde syndrome."

D. "Methadone increases the client's risk for acetaldehyde syndrome."

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client'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 her 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."

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates the need for further teaching? A. "Rape is a crime of aggression." B. "Acquaintance rape often involves alcohol." C. "Both men and women can be victims of rape." D. "The majority of rapists are unknown to the victims."

D. "The majority of rapists are unknown to the victims."

A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructor's best response. A. "Other students get caught as well." B. "I am not trying to cause you to fail. I am here to help you." C. "I am sorry you feel that way. I try to treat all my students equally." D. "The requirements for this experience were discussed during our orientation."

D. "The requirements for this experience were discussed during our orientation." The student is demonstrating projection, as evidenced by not taking responsibility for his / her own behavior and blaming the instructor. In the correct answer, the instructor should avoid a defensive response, and reinforce that the responsibility belongs to the student.

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "To assess cognitive ability, I should ask the client to count backward by 7." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects."

D. "To assess remote memory, I should have the client repeat a list of objects." This statement requires further teaching. Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory

A pt was diagnosed w BPD many years ago. The pt tells the RN, "When I have a manic episode, there's always a feeling of gloom behind it and I know I will soon be totally depressed." What is the nurse's best response? A. "Most pts diagnosed with BPD report the same types of feelings." B. "Feelings of gloom associated with depression result from serotonin dysregulation." C. "If you take your medication as it is prescribed, you will not have these experiences." D. "Your comment indicates you have an understanding and insight about your disorder."

D. "Your comment indicates you have an understanding and insight about your disorder."

A pt is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the pt's lab results below. NA 143 K 3.1 Cl 102 Mg 2.2 Ca 8.4 Phosphate 3 The nurse should take which next action? A. Measure the pt's body temp. B. Inspect the pt's skin and sclera for jaundice. C. Assess the pt's mucous membranes for erosion. D. Auscultate the pt's heart rate, rhythm, and sounds.

D. Auscultate the pt's heart rate, rhythm, and sounds.

A nurse is assessing a client who is the victim of sexual assault. Which of the following findings indicate the client is experiencing an initial impact reaction of rape-trauma syndrome? (Select all that apply.) A. Genitourinary soreness from the assault B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

D. Emotional outbursts E. Difficulty making decisions

A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client's plan of care? A. Allow the client to select preferred meal times. B. Establish consequences for purging behavior. C. Provide the client with a high-fat diet at the start of treatment. D. Implement one-to-one observation during meal times.

D. Implement one-to-one observation during meal times.

A victim of reported sexual assault tells the RN, "This was entirely my fault. I should never have gone to that party alone." Which response by the RN is most therapeautic? A. this was a freightening experience for you B. what do you think you should have done differently C. Would you like to tell me more about what happened D. It sounds like you're blaming yourself for the assailants behavior.

D. It sounds like you're blaming yourself for the assailants behavior.

A pt on an acute psychiatric unit removed the cap from the ceiling sprinkler, resulting in rapid flooding of the unit. After moving pts to a safe area, which action should the RN take next? A. Conduct individual sessions w pts regarding the experience. B. Increase the volume of overhead music to distract pts from the event. C. Implement a psychomotor activity to reduce anxiety associated w the event D. Lead a group session w the pts to discuss feelings associated w the event.

D. Lead a group session w the pts to discuss feelings associated w the event.

A nurse in an acute mental health facility is caring for a client who is experiencing a mixed episode of bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.

D. Monitor the client for escalating behavior.

An RN leads a bereavement group. Which participant's comment best demonstrates that the work of grief has been successfully completed? A. Our time together was too short. I only wish we had done more things together. B. I know our life together was a blessing that I did not deserve. I wish I had said 'I love you' more often C. Other people knew mt loved one as a good and helpful person. I hope people see me in the same way. D. Our best vacations always involved water. When I see pictures of the oceans, those memories come flooding back in.

D. Our best vacations always involved water. When I see pictures of the oceans, those memories come flooding back in.

An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for 5 years, never knowing when something else will go wrong." What is the nurses priority intervention regarding the spouse? A. Explore the spouse's feelings, showing care and compassion B. Encourage the spouse to attend a community support group C. Teach stress reduction and relaxation techniques to the spouse D. Refer the spouse to the primary care provider for health assessment

D. Refer the spouse to the primary care provider for health assessment The scenario suggests the spouse has experience long term stress. When stress is prolonged, the body stays alert. Chemical produced by stress response can have damaging effects on the body, causing physiological diseases.

A nurse is caring for a school age child who has a new prescription for methylphenidate (Daytrana) to treat ADHD. Which of the following should the nurse teach the client and family about this medication? A. Apply the patch once daily at bedtime. B. Take the medication orally with food every 12 hr. C. Take a second dose of the medication orally at bedtime. D. Remove the patch each day after 9 hr.

D. Remove the patch each day after 9 hr.

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam (Valium) for generalized anxiety disorder. Which of the following is appropriate for the nurse to include in the teaching? A. 3 to 6 weeks of treatment is required to achieve therapeutic benefit. B. Combining alcohol with diazepam will produce a paradoxical response. C. Diazepam has a lower risk for dependency than other antianxiety medications. D. Report confusion as a potential indication of toxicity

D. Report confusion as a potential indication of toxicity

An adult diagnosed with stage 2 Alzheimer's disease begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the higest priority to add to the plan of care? A. Risk for constipation B. Risk for altered sensory perception C. Risk for impaired oral mucous membranes D. Risk for imbalanced nutrition, less than body requirements

D. Risk for imbalanced nutrition, less than body requirements

A pt tells the RN, "No matter what I do, I feel like there's always a dark cloud following me." Select the RN's initial action. A. Assess the pt's current sleep and eating patterns B. Explain to the pt, "everyone feels down from time to time." C. Suggesting alternative activities for times when the pt feels depressed D. Say to the pt, "Tell me more about what you mean by 'a dark cloud'.

D. Say to the pt, "Tell me more about what you mean by 'a dark cloud'.

An outpatient psychiatric nurse assesses a patient diagnosed with hoarding disorder. The patient has lost 12 lbs in the past two months, appears disheveled, and is wearing dirty clothing w poor hygiene. What is the nurse's priority action? A. Review the patient's medication regimen. B. Ask the patient "What types of foods have you been eating?" C. Refer the pt to a psychologist for CBT. D. Schedule a home visit to assess the safety of the pt's living conditions.

D. Schedule a home visit to assess the safety of the pt's living conditions.

A nurse is caring for a client who is experiencing a panic attack. Which of the following is an appropriate nursing intervention? A. Discuss new relaxation techniques. B. Show the client how to change his behavior. C. Distract the client with a television show. D. Stay with the client, and remain quiet.

D. Stay with the client, and remain quiet.

A recently widowed adult says, "I've been calling my neighbors often but they act like they don't want to talk to me. I just need to talk about it, you know?" What is the RN's best action? A. Say to the person "You can call me anytime you need to talk." B. ask the person "what do you mean by 'I just need to talk about it?'" C. educate the person about the importance of finding alternative activities D. Tell the person the location and time of a local bereavement support group.

D. Tell the person the location and time of a local bereavement support group.

A female RN is appointed to a committee w several men. At the beginning of the meeting, the chairman asks the RN to be the secretary. The RN responds, "NO. you're just asking me to be the secretary because im the only woman here." Which response would have been more effective? A. THere are others more qualified than I am to be secretary B. I would be glad to preform another role for our committee C. I'm probably overreacting, but I find your request offensive. D. Thank you for asking, but your request is sexually discriminatory NOT SURE

D. Thank you for asking, but your request is sexually discriminatory NOT SURE BOOK SAYS B. I would be glad to preform another role for our committee because it is assertive .... is this correct

The nurse prepares outcomes to the plan of care for an adult diagnosed with mental illness. Which strategy recognizes the current focus of treatment services for this population? A. The patient's diagnoses are confirmed using advanced neuroimaging techniques. B. The nurse confers with the treatment team to verify the patient's most significant disability. C. The nurse prioritizes the patient's problems in accordance with Maslow's hierarchy of needs D. The patient and family participate actively in establishing priorities and selecting interventions

D. The patient and family participate actively in establishing priorities and selecting interventions

A combat veteran from two tours of the war in Afghanistan tells the nurse, "Some guys in my unit have PTSD, but I never had any problems other than my hearing is not as good as it once was." Which explanation for this comment should the nurse consider? A. The veteran wants to demonstrate toughness and strength. B. The veteran shows indicators of depersonalization and derealization. C. The veteran may be rationalizing this reaction to memories of combat. D. The veteran may have amnesia associated with the combat experience.

D. The veteran may have amnesia associated with the combat experience.

A community mental health RN talks w a 6 y/o child who's divorced parents have shared custody. Which initial question will best help the RN explore the child's perception of home life? A. Is your life different from your friends lives? B. are you happiest at your mother or your fathers house? C. do you find it hard to move back and forth between homes? D. What are some of the good and bad things about living in two places?

D. What are some of the good and bad things about living in two places?

A patient has been oppositional, demanding, and resistant to working on goals. A mental health nurse tells the nursing supervisor, "We finally had a serious talk. I let that patient know it's time to get right with God and stop this behavior." Recognizing the nurse's actions were not acceptable, select the supervisor's responding action. A. Review the facility policies regarding patient's rights with the nurse. B. Ask the nurse about documentation related to this patient interaction. C. Schedule the nurse for a staff development activity on cultural sensitivity. D. Work with the nurse to prepare and analyze a process recording of the interaction.

D. Work with the nurse to prepare and analyze a process recording of the interaction.

An RN assesses a 78 y/o pt who lives alone at home and is beginning 3 new RX. Which question by the RN will provide best for the pts safety? A. How do you store your medications at home? B. What is your usual bowel elimination pattern? C. who usually helps you w your medications? D. how much alcohol do you drink on a normal day?

D. how much alcohol do you drink on a normal day?

single adult says to the RN, "Both of my parents died several years ago and my only sibling died 2 weeks ago. I feel so alone." After determining that the adult has no suicidal ideation, the RN should: A. Explore the adult's feelings of survival guilt B. Assess the adult's cultural beliefs and spirituality C. Refer the adult for CBT D. refer the adult for a self help group for suicide survivors

D. refer the adult for a self help group for suicide survivors

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding? A."You really should complete your own work. I don't think it's right to expect me to complete your responsibilities." B."Why do you expect me to finish your work? You must realize that I have my own responsibilities." C."It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D."When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

D."When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

A nurse is providing teaching for a client who is scheduled to receive ECt for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A."it is common to treat depression with eCt before trying medications." B."i can have my depression cured if i receive a series of eCt treatments." C."i should receive eCt once a week for 6 weeks." D."i will receive a muscle relaxant to protect me from injury during eCt."

D."i will receive a muscle relaxant to protect me from injury during eCt."

A charge nurse is discussing tmS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a."tmS is indicated for clients who have schizophrenia spectrum disorders." B."i will provide postanesthesia care following tmS." C."tmS treatments usually last 5 to 10 minutes." D."i will schedule the client for daily tmS treatments for the first several weeks."

D."i will schedule the client for daily tmS treatments for the first several weeks."

a nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? a."i will write down my dreams as soon as i wake up." B."i may begin to associate my therapist with important people in my life." c."i can learn to express myself in a nonaggressive manner." d."i should say the first thing that comes to my mind."

d."i should say the first thing that comes to my mind."