Unit 1 Pearson Practice Questions

Which assessment should be considered as priority by the nurse caring for a client with major depression? a.1.Client's current mood and affect 2.Client's response to medications 3.Client's risk for suicidal behaviors 4.Client's decision-making abilities

3.Client's risk for suicidal behaviors

A client admitted to the hospital for a recent suicide attempt has been taking antidepressants as prescribed and attending group therapy. The client is sleeping 6 hours per night and reports a significant improvement in mood. The client states, "I have lots of things to do when I get home, and I don't really need to be in the hospital anymore." Which response by the nurse would be most appropriate? a."Are you still having thoughts of suicide?" b."Are you willing to sign a 'no-harm' contract before you leave?" c."How would you rate your mood on a scale of 1 to 10?" d."How can we be sure you won't hurt yourself when you go home?"

a."Are you still having thoughts of suicide?"

A client who attempted suicide 5 years ago with an overdose was brought to the emergency department by a friend. The client states, "I just don't feel like living anymore. No one would care if I lived or died." What question should the nurse ask next? a."Do you have a plan for suicide at this time?" b."What major losses have you experienced in the past 6 months?" c."Have you experienced any major life crises in the past 6 months?" d."Do you feel angry, overwhelmed, or hopeless?"

a."Do you have a plan for suicide at this time?"

A client is admitted to the nursing unit with fever and dehydration, which have caused the client to experience delirium. The nurse expects which treatment to be ordered for this client? a.Acetaminophen and IV fluids b.Provide a stimulating environment c.Psychotropic medications d.Drugs to assist the memory

a.Acetaminophen and IV fluids

A client in the hospital in a hypomanic state comes to the common room dressed in a sexually suggestive manner and is making sexual remarks and gestures. What is the appropriate nursing action? a.Approach the client calmly and escort the client back to the client's room. b.Insist that the client leave the common room. c.Confront the client regarding dress and mannerisms in the common room. d.Tell the other clients to ignore the behavior.

a.Approach the client calmly and escort the client back to the client's room.

The nurse is working with an older adult client and is aware that symptoms of depression may be related to life changes. With which life change would the nurse be most likely to be concerned as being related to depression? a.Death of a spouse b.Purchasing a new car c.Friends moving away d.Change in activity level

a.Death of a spouse

A client with a personality disorder has a nursing diagnosis of Impaired Social Interaction. Applying the principles for caring with this client, which of the following nursing interventions is essential to the care plan? a.Demonstrate honesty and sincerity in interactions with client. b.Assist the client in identifying personal strengths. c.Demonstrate unconditional positive regard when confronting inappropriate behavior. d.Model assertive communication.

a.Demonstrate honesty and sincerity in interactions with client.

The nurse is caring for a client who is manic and exhibiting psychomotor agitation. Which nursing action would be most effective? a.Implement limit setting with the client. b.Explore causes of the manic behavior. c.Administer antidepressants as ordered. d.Discuss alternative behaviors with the client.

a.Implement limit setting with the client.

The therapeutic team has identified the need to formulate strategies for dealing with a client's inappropriate behavior and maintaining a safe environment for the other clients on the unit. Which intervention strategy must be initiated immediately? a.Monitor the client's behavior. b.Identify the client's thought process that leads to this behavior. c.Help the client to identify why the client demonstrates this behavior. d.Teach appropriate interpersonal skills to the client.

a.Monitor the client's behavior.

The nurse discusses the disease process of Alzheimer disease with the client and caregiver. What does the nurse explain is the cause of Alzheimer disease? a.The cause is unknown. Amyloid plaques and neurofibrillary tangles have been found in the brain at autopsy. b.The cause is unknown. Chronic small intracranial bleeds have been found on CT scans. c.Loss of circulation to the brain has been found on CT scans. d.Loss of dopamine receptors is thought to occur as a part of the aging process.

a.The cause is unknown. Amyloid plaques and neurofibrillary tangles have been found in the brain at autopsy

The nurse is caring for a client with obsessive-compulsive personality disorder. Most of the client's cognitive content will be centered on which of the following? a.The importance of rules and regulations b.Global approaches to solving problems c.Relationships with others d.Preferred leisure activities

a.The importance of rules and regulations

The nurse is caring for a client who was involved in a traumatic event a week ago. The client's family member expresses that the client is experiencing posttraumatic stress disorder. What is the nurse's best response to the client's family member? a."Yes, what your family member is experiencing is posttraumatic stress disorder." b."At this time, your family member is experiencing acute stress disorder because the event has just recently occurred." c."It is hard to tell at this time if your family member is truly experiencing posttraumatic stress disorder." d."Posttraumatic stress disorder only happens when an individual is in the military."

b."At this time, your family member is experiencing acute stress disorder because the event has just recently occurred."

The nurse is caring for an older adult who is exhibiting symptoms of a personality disorder. The client states he has never been diagnosed with a personality disorder before. The nurse would want to ask the client which of the following statements first? a."Do you have a family history of mental illness?" b."Have you recently had a loss of a person or situation in your life?" c."Are you sure you have not been diagnosed with a personality disorder earlier in your life?" d."Tell me about your childhood."

b."Have you recently had a loss of a person or situation in your life?"

The spouse of a client who is experiencing delirium from dehydration is concerned about taking the client home in a confused state. The nurse would respond with which correct statement? a."I'll teach you how to make your home safe." b."Once the dehydration is corrected, your spouse will no longer be delirious." c."We'll be ordering a home health aide to help you." d."Oh, it won't be so bad; the client is harmless."

b."Once the dehydration is corrected, your spouse will no longer be delirious."

The spouse of a client on lithium for bipolar disorder tells the nurse that the client is experiencing slurred speech, muscle weakness, and diarrhea. The spouse reports the client's lithium level is 2.0 mEq/L. What should the nurse tell the spouse to assist with coping? a."This level is sub-therapeutic and an increase in the medication will need to be made to reach the therapeutic range." b."This level is above the therapeutic range and the client's symptoms are related to this level." c."This level is within therapeutic range but may need to be higher to meet the client's individual needs." d."There is not a therapeutic range for lithium. It is dosed to address the symptoms that the client is exhibiting."

b."This level is above the therapeutic range and the client's symptoms are related to this level."

Which medication would the nurse expect to administer to a client who is experiencing ritualistic behavior that interferes with job performance and activities of daily living? a.Fluphenazine (Prolixin) b.Fluoxetine (Prozac) c.Lorazepam (Ativan) d.Carbamazepine (Tegretol)

b.Fluoxetine (Prozac)

The nurse is caring for a client diagnosed with borderline personality disorder. Which assessment finding is consistent with the social traits associated with this diagnosis? a.High-risk sexual behaviors b.Intense fear of abandonment c.Controlling and abusive behaviors d.Disinterest in intimate relationships

b.Intense fear of abandonment

The nurse is talking to a pre-teen group of students at a community center. The nurse explains the importance of a student reporting to an adult when a friend states the thought of committing suicide. What is the reason the nurse would include this information? a.This is so the student with the thought of suicide can be reported to the police. b.Many students who tell someone follow through with suicide plans and actions can be put in place to protect the student. c.The student with thoughts of suicide should be admitted to an inpatient psychiatric facility immediately. d.Data is being collected for a local and state study of pre-teen suicide attempts.

b.Many students who tell someone follow through with suicide plans and actions can be put in place to protect the student.

The nurse is caring for a 4-year-old child with posttraumatic stress disorder. The nurse is aware that the child is exhibiting age-appropriate manifestations of posttraumatic stress disorder when the child exhibits which behavior? a.Guilt b.Nocturnal enuresis c.Attempted suicide d.Poor concentration

b.Nocturnal enuresis

The nurse is planning care for a newly admitted client who is experiencing hypomania. The nurse selects the nursing diagnosis of Risk for Injury based on which finding? a.Good defensive abilities of the client b.Possible attacks by other clients c.Good judgment by the client d.Lack of impulsivity of the client

b.Possible attacks by other clients

The nurse states to a client, "In the past, you have made your appointments very well on your own." What is the most likely rationale for the nurse's action? a.Showing consistency in nursing actions b.Rewarding appropriate behavior c.Reinforcing the client's sense of mastery d.Clarifying discharge goals

b.Rewarding appropriate behavior

The nurse is caring for a 10-year-old child who has meningitis and is delirious. Which is a priority nursing diagnosis for this client? a.Anxiety b.Risk for Injury c.Ineffective Airway Clearance d.Activity Intolerance

b.Risk for Injury

A nurse is teaching a group of high school students about eating disorders. The nurse plans to include in the teaching that cultural stereotypes may contribute to the development of eating disorders in which of the following ways? a.Eating disorders result from biological and genetic factors. b.The culture has a strong emphasis on low body weight justifying high self-esteem. c.Stereotypes identify the population at risk for eating disorders. d.Cultural stereotypes increase an individual's insight regarding personal weight issues.

b.The culture has a strong emphasis on low body weight justifying high self-esteem.

The nurse is caring for a 22-year-old female client who is diagnosed with schizophrenia. The nurse would anticipate which family member is at highest risk for having the disorder? a.Maternal uncle b.Younger brother c.First-degree cousin d.Paternal grandmother

b.Younger brother

The nurse is working with families of clients with Alzheimer disease. One of the members says, "I feel so sad because my loved one is lost." What response by the nurse can best facilitate group discussion on this issue? a."Grieving for a lost relationship is a normal behavior." b."Are you experiencing anger about this?" c."How have others in the group dealt with these feelings?" d."You will not feel sad as soon as you can accept your loved one's illness."

c."How have others in the group dealt with these feelings?"

The nurse working with the family of a client with suicidal ideations is asked whether the antipsychotic medication the client is taking will prevent suicide. What is the nurse's best response? a."Clients who take the medication as prescribed are at decreased risk for suicide." b."Medication helps treat an underlying mood disorder associated with suicidal thinking and therefore prevents suicide." c."Medication helps decrease the frequency and intensity of suicidal thoughts." d."The client states that no more attempts will be made at suicide, so you don't need to worry."

c."Medication helps decrease the frequency and intensity of suicidal thoughts."

The nurse would look for which of the following characteristics in the behavior of a client experiencing obsessive-compulsive personality disorder (OCPD)? a.Dramatic, erratic b.Odd, eccentric c.Anxious, fearful d.Rigid, critical

c.Anxious, fearful

The nurse is documenting an interaction with a client and is describing the intensity of emotions displayed in the client's affect. What word would the nurse use to describe that the client's emotions are dulled or muted given the situation? a.Moderate b.Overreactive c.Blunted d.Flat

c.Blunted

The nurse is caring for the older adult client and is aware that many conditions can cause signs and symptoms of delirium. Which factor in the older adult client is least likely to cause delirium? a.Urinary tract infection b.Dehydration c.Gout d.Urinary retention

c.Gout

An 83-year-old client is in the emergency department and is acting in a bizarre manner. The client is being treated for otitis media. Which sign will the nurse recognize as indicating that the client is delirious? a.1.Sundowning symptoms b.Gradual onset of symptoms c.Impaired thinking skills d.Specific attention to detail

c.Impaired thinking skills

The nurse is promoting a therapeutic environment for a client with delirium and congestive heart failure. Which intervention will the nurse initiate for this client? a.Keep the drapes over the windows closed at all times. b.Avoid medicating client with any type of pain medication. c.Maintain appropriate levels of noise in the room to avoid overstimulation. d.Discourage family and loved ones visiting the client.

c.Maintain appropriate levels of noise in the room to avoid overstimulation.

The nurse is caring for women in the outpatient clinic who are pregnant. The nurse is aware of a condition where individuals eat non-food items. The nurse is aware that this condition is known as which of the following? a.Marasmus b.Pellagra c.Pica d.Scurvy

c.Pica

Which manifestation is usually the first indication of the onset of Alzheimer disease? a.Inability to perform activities of daily living (ADLs) b.Sundowning at night c.Subtle memory deficits d.Inability to communicate

c.Subtle memory deficits

The nurse is caring for a pregnant client with a history of bipolar disorder. What does the nurse know about the pregnant client's risk of a bipolar episode while she is pregnant? a.Pregnant women do not have bipolar episodes due to their estrogen levels during pregnancy. b.Most pregnant women with bipolar disorder experience at least one manic episode while pregnant. c.The pregnant client is 5-10 times more likely to have a bipolar episode during pregnancy. d.If the pregnant client continues to take the same dosage of medication, there is no risk of a bipolar episode.

c.The pregnant client is 5-10 times more likely to have a bipolar episode during pregnancy.

The client states that taking medications causes sexual dysfunction. The client has not taken the prescribed antipsychotic drug for the past 2 weeks. The nurse anticipates which occurrence? a.Hypertensive crisis may occur. b.Muscle twitching may occur. c.Parkinson-like symptoms may occur. d.Agitation may occur.

d.Agitation may occur.

The nurse is speaking to a client who grew up with an aunt who had schizophrenia and asks the nurse to explain the genetic component of developing schizophrenia. What response accurately describes genetics and schizophrenia? a.One single gene is responsible for producing schizophrenia. b.There is strong evidence that genetic factors do not affect the risk of developing schizophrenia. c.The chance of monozygotic (identical) twins both having schizophrenia is 100%, thus demonstrating the high level of genetic influence in schizophrenia. d.An individual has an almost 50% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

d.An individual has an almost 50% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

A nurse is talking with a parent about the toddler's medical diagnosis of avoidant/restrictive food intake disorder (ARFID). The nurse explains to the parent that a child with ARFID could avoid foods for all of the following reasons except which reason? a.Color b.Consistency c.Texture d.Calorie density

d.Calorie density

The nurse is caring for two assigned clients, one with anorexia and the other with bulimia. The nurse expects that the most common coexisting mental health issue with both clients is which of the following? a.Anxiety b.Panic attacks c.Agoraphobia d.Depression

d.Depression

The nurse is interviewing a client admitted with anorexia and expects to find that the client manages anxiety in which of the following ways? a.Reinforces self-approval b.Needs to be perfect with decision making c.Breaks rules d.Follows rigid rules

d.Follows rigid rules

The nurse should monitor the client with bulimia nervosa for which complication? a.Metabolic alkalosis b.Pulmonary effusion c.Excessive salivation d.Orthostatic hypotension

d.Orthostatic hypotension

The nurse caring for a client with obsessive-compulsive disorder (OCD) will expect to assess for which finding? a.Self-mutilation b.Fear of inability to escape c.Excessive dependence d.Ritualistic behaviors

d.Ritualistic behaviors