384 Final Practice Questions

A nurse is caring for a client who has an alcohol use d/o and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time?

A. Administer substitution therapy medications

A nurse is planning a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation?

C. Older adults are at an increased risk for substance use following retirement.

A nurse is caring for a client who is becoming aggressive. Which of the following de-escalation techniques should the nurse use? (SATA)

A. Approach the client with respect B. Respond to the client's concerns D. Address the client in a soft voice

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (SATA)

B. Fine tremors of both hands D. Vomiting E. Restlessness

A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam?

B. Increased Blood Pressure

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

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

A nurse is planning care for a client who has completed detoxification from opioid abuse d/o. The nurse should plan to teach about which of the following medications?

B. Naltrexone

A nurse is caring for an adult client who has injuries resulting from spousal violence. 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 safe houses and shelters.

A nurse is giving a presentation on various types of therapy to a group of staff nurses. Which of the following therapies is the nurse describing when discussing a therapy that uses psychoeducation to change thought patterns?

B. Schema Therapy

A nurse is developing a plan of care for a client who has alcohol use dx. Which of the following medications should the nurse plan to administer?

D. Diazepam

A nurse is preparing educational material for guardians on trauma prevention, and developing childhood resilience. Which of the following techniques should the nurse include? (SATA)

A. Foster a hopeful perspective of the future B. Encourage development of thinking and learning C. Provide secured and supportive relationships and places

A nurse is observing 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 underlying reasons?

C. Attempt to reduce anxiety

A nurse is caring for a client who states that they are entitled to a single room on the mental health unit and that the nurse is not educated enough to care for them. The nurse should identify that this finding is consistent with which of the following personality d/o?

A. Narcissistic Personality d/o

A nurse is providing education to a group of clients about addiction. The nurse should include which of the following as a definition of addiction?

A. Recurring, uncontrollable urges to engage in compulsive behaviors such as substance use in spite of negative consequences.

A nurse is caring for a client who has borderline personality d/o. Which of the following manifestations should the nurse expect?

A. Self-mutilation

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should inform the client that which of the following adverse effects can occur with abrupt withdrawal of phenytoin?

A. Status Epilepticus

A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. Which of the following dietary items should the nurse instruct the client to avoid?

B. Pure Vanilla Extract

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (SATA)

B. Respiratory distress C. Retinal hemorrhage D. ALOC E. Increase in head circumference

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality d/o. Which of the following findings should the nurse expect? (SATA)

C. Attempts to convince other clients to relinquish their belongings E. Blames others for personal past and current problems.

A nurse is caring for a client who is speaking loudly and threatening to harm staff and other clients. Which of the following medications should the nurse anticipate the provider prescribing for this client?

C. Chlorpromazine

A nurse is providing substance use education to a group of parents. The nurse should include which of the following factors that contribute to teenagers being at risk for substance use d/o?

C. Decision-making, judgement, and self-control are not fully mature in teenagers

A nurse is caring for a client who has alcohol use d/o . The client is on longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?

C. Disulfiram

For each finding, click to specify if the finding is consistent with schizoid personality d/o, schizotypal personality d/o, or paranoid personality d/o.

Schizoid Personality d/o --> feelings of depersonalization, social withdrawal, isolation Schizotypal Personality d/o --> suspiciousness, unsupported by evidence, blaming others of their social isolation Paranoid Personality d/o --> suspiciousness, unsupported by evidence, unwillingness to forgive others, jealousy, controlling behaviors

Nxt Gen Complete the following sentence by using the lists of options. A nurse is caring for a client in a detoxification unit. Hx and physical: Day 1 Admission Note: 55-year -old client admitted with long-standing hx of alcohol use d/o/ Recently involved in motor vehicle accident and now seeking inpatient detoxification and tx for alcohol use d/o. Blood alcohol level at time of accident is 0.33 mg/dl. Reports drinking "hard liquor" since age 14. Also states, "I drink about 10 to 12 drinks of vodka a day." Nurses Notes: Day 1: 0800: Client reports drinking "several shots of vodka yesterday." Tremulousness of hands noted. Client refuses food currently, stating, "I am nauseated." 1600: Assisted client to complete the Clinical Institute withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) document. Client's score is 32.

The client is at highest risk for developing severe and complicated withdrawal evidenced by the client's CIWA-Ar Score.

A nurse is meeting with a new client at a substance use d/o clinic. During the meeting, the nurse learns from the client that they were treated for both asthma and anxiety as a child. The nurse is collecting which of the following types of data from the client's account?

A. Historical

A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following findings should the nurse expect? (SATA)

A. Difficulty concentrating on tasks C. Negative self-image D. Recurring nightmares

A charge nurse is preparing a staff education session on personality d/o. Which of the following personality characteristics associated with all of the personality d/os should the charge nurse include in the teaching? (SATA)

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 providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide?

A. Eat a diet high in fiber

A nurse is working with local crisis response team to evaluate students following a school shooting. After ensuring the safety of the students, which of the following trauma-informed approaches should the team take next?

A. Establish a supportive environment that facilitates trust and transparency.

A nurse is developing a plan of care for a 14-year -old client who has a hx of child maltreatment. The staff have reported that any time an alarm occurs, the client is found sitting in a closet. Which of the following most accurately describes the client's response?

A. Fear Conditioning

A nurse is caring for a client who has avoidant personality d/o. Which of the following statements is expected from a client who has this type of personality d/o?

A) "I'm scared that you're going to leave me."

A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? (SATA)

A. "Methadone is a replacement for physical dependence of opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." E. :Methadone must be prescribed and dispensed by an approved tx center."

A nurse is caring for a client who is experiencing extreme anger. Which of the following client statements should the nurse identify as being consistent with adverse childhood experiences (ACEs)? (SATA)

A. "My parents separated when I was 9 years old." B. "My sibling and I would stay alone for days at a time while my parent was gone." C. "My older sibling died of a heroin toxicity when I was 12 year old." E. "My parent used to hit my sibling and I with a belt when we were younger." F. "When I was younger, I experienced drive-by shootings in my neighborhood."

A nurse is providing teaching to a client who has alcohol use d/o and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching?

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

A nurse is caring for a client who states, "I have no close friends. I do not go to parties. I can't talk in front of people, and I fear rejections." The nurse should identify that these findings are manifestations of which of the following personality d/os?

A. Avoidant Personality d/o

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (SATA)

A. Conducting a suicide risk screening on all new clients C. Educating high school teens about suicide prevention E. Teaching middle-school educators about warning indicators of suicide

A nurse on a mental health unit is teaching a newly licensed nurse about psychotic features among clients. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

D. "Clients who have borderline personality d/o can exhibit psychotic features."

A nurse at a clinic is screening clients for trauma. The nurse should identify that which of the following factors increases a client's risk for developing a trauma-related d/o? (SATA)

A. The client has a hx of physical abuse B. The client belongs to a marginalized group C. The client was active military during the Iraq war

A nurse is assessing a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache, and extreme thirst. The nurse should identify that which of the following situations is occurring?

A. The client is experiencing mild acetaldehyde syndrome

A nurse is caring for a client who has PTSD. Which of the following actions by the client indicates the current plan is effective?

A. The client reports techniques she uses to promote sleep

A nurse is observing a client who has histrionic personality d/o. Which of the following behaviors should the nurse expect?

A. The client whispers in the provider's ear

A nurse is caring for a client who is demonstrating aggressive behavior towards others and is not responding to verbal interventions. Which of the following medications should the anticipate the provider prescribing?

A. Ziprasidone

A nurse in the emergency department is caring for a client who states they fell down the stairs this morning. Which of the following assessment findings indicates the client might be experiencing physical abuse? (SATA)

A. the client has bruises in various stages of healing on their back B. the client's eyeglasses are cracked C. The client is visibly uneasy when their partner enters the area E. The client has ligature marks around both wrist F. The client has an open, discolored wound on their shoulder

A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence?

D. "I only got shoved a little bit, and it was my fault for coming home late."

A nurse is providing teaching to the family of a client who has a substance use d/o. Which of the following statements by a family member indicates an understanding of the teaching? (SATA)

B. "Eliminating codependent behavior will promote recovery." D. "The primary goal of tx is abstinence from substance use." E. "Our sibling needs to discuss personal feelings about substance use to help with recovery."

A nurse is providing teaching to a client who has a new prescription of diazepam. Which of the following instructions should the nurse include in the teaching?

B. "This medication can be habit-forming."

A nurse is evaluating a client's understanding of a new prescription for clonidine for the tx of opioid use d/o. Which of the following statements by the client indicates an understanding of the teaching?

B. "While taking this medication, I should keep a pack of sugarless gum."

A nurse is developing a d/c plan for a client who is in substance use rehabilitation. The nurse should include which of the following tx modalities to decrease the likelihood of relapse?

B. 12-setp programs, cognitive-behavioral therapy, support groups

A nurse is caring for a client who is hospitalized for gallbladder removal surgery. On their first postoperative day, the client has agitation, a high temperature, increased respirations, irritability, and confusion. The nurse should recognize that the client may be experiencing withdrawal from which of the following substances?

B. Alcohol

A nurse is caring for a client who has borderline personality d/o. The nurse should identify that which of the following factors may have contributed to the development of this d/o?

B. Childhood Rejection

A nurse is developing education for a parenting class about adverse childhood events (ACEs). Which of the following statements should the nurse include in the education?

B. Children who are exposed to repeated adverse childhood events are at an increased risk for developing physical and mental health issues."

A nurse is caring for a client who is receiving tx for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

B. Diazepam

A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

B. Dilated Pupils

A nurse is assessing a client who has an anxiety d/o and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client?

B. Dizziness

A nurse is caring for a client who has antisocial personality d/o. Which of the following actions should the nurse take?

B. Ensure staff members set limits on the client's behavior

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 an understanding of teaching?

D. "Pregnancy increases the risk for violence from a spouse or partner."

A nurse is providing teaching to a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make?

D. "The medication might cause you to have episodes of diarrhea."

A nurse is analyzing assessment data for a group of clients. Which of the following clients is at risk of developing PTSD?

D. A 36-year-old client who has a maxillofacial fracture caused by their partner

A nurse is caring for a client who was recently dx with PTSD. The client ask, "What is the difference between acute stress d/o and PTSD?" Which of the following responses should the nurse make?

B. PTSD is dx if the symptoms persist for longer than 1 month

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (SATA)

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

A nurse is caring for a client who has borderline personality d/o. The clients 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?

B. Splitting

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations now include anxiety, tremors, BP 166/100 mm Hg, and tachypnea. The nurse should recognize that the client is experiencing which of the following stages of withdrawal from alcohol?

B. Stage 2 (moderate)

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related d/o? (SATA)

B. Take breaks during the incident for food and water C. Debrief with others following the incident E. Take advantage of offered counseling

A nurse is caring for a client who has obsessive-compulsive d/o. The client's behaviors likely originate in which of the following brain circuits?

B. The cortico-striato-thalamocortical circuit

A nurse is caring for a client who has Cluster C personality d/o and is helping the client explore ways to cope with anxiety. Which of the following actions should the nurse tell the client has been shown to decrease anxiety?

D. Adopting a pet

A nurse is assessing a client with psychotic d/o who has a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is this client likely experiencing?

D. Akathisia

A nurse in a emergency department is caring for a client and finds a razor blade hidden in the client's personal belongings. The nurse should identify that this findings is consistent with which of the following d/o?

D. Borderline Personality d/o

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?

D. Ensure that the client swallows medications

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 an understanding of the teaching?

C) "I should practice limit-setting to help prevent client manipulation."

A nurse on an inpatient mental health unit is having a conversation with a client who is exhibiting manifestations similar to obsessive-compulsive d/o. Which of the following statements by the nurse reflects appropriate understanding of risk factors for developing manifestations of obsessive-compulsive d/o?

C. "I would like to know more about the manifestations that you share with your biological father."

A nurse is meeting with a new client at a substance use d/o clinic. The nurse should take which of the following actions during the assessment phase of the nursing process?

C. Ask the client for information regarding their current problem, identify signs and symptoms, and use screening tools as appropriate.

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol? (SATA)

C. Disulfiram D. Naltrexone E. Acamprosate

A nurse is caring for a client who reports that their partner threatens them when they disagree about finances. The nurse should identify that the client is experiencing which of the following types of abuse?

C. Emotional

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing a staff member against another. Which of the following actions should the nurse take?

C. Explore with the client his use of clinging and distancing behaviors

A nurse is reviewing the medical record of a client who has a new prescription for benzodiazepine. For which of the following findings should the nurse question the provider's prescription?

C. Hypotension

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?

C. Implement seizure precautions

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome?

C. Report of intense guilt

A nurse on an inpatient rehabilitation units is assessing a client who has a hx of opioid use d/o and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

C. Rhinorrhea

A nurse is assessing a client who has schizophrenia and takes haloperidol 3xs daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. The nurse should identify that these manifestations indicate which of the following adverse effects to haloperidol?

C. Tardive Dyskinesia

A nurse on a mental health unit is planning care for a client who has borderline personality d/o. Which of the following goals should the nurse set for the client?

C. The client will have no emotional outbursts during group therapy for a week

A nurse is assessing a client who has a hx of alcohol use d/o and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal?

D. Hallucinations

A nurse in the emergency department is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

D. Hypervigilance (different set of choices that the question before)

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse prepare to administer?

D. Lorazepam ***FIRST CHOICE***

A nurse is assessing a client who is experiencing PTSD following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe?

D. Paroxetine

A nurse at an acute care facility is caring for a client receiving IV antibiotic tx for an infection. The client reports daily alcohol use at home. On the second day of admission, the client becomes agitated and has a blood pressure of 195/102 mmHg and a heart rate if 118 bpm. Which of the following actions should the nurse plan to take?

D. Request a prescription for chlordiazepoxide

A nurse is presenting an in-service on the cycle of violence to nursing staff. The nurse should include that the perpetrator becomes affectionate at which of the following phases?

D. Respite

A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders?

D. Schizotypal

A nurse is collecting an admission hx for a client who has acute stress d/o (ASD). Which of the following client behaviors should the nurse expect?

D. The client expresses a sense of unreality about the traumatic incident

A nurse is caring for a client who is concerned about developing a mental health d/o. Which of the following statements regarding the relationship between adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) is correct?

D. The presence of PCEs can provide some degrees of symptomatic protection from ACEs in certain instances.

A nurse is caring for a client who has PTSD and who is undergoing eye movement desensitization and reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies?

D. Uses stimuli to change how the client processes the trauma

Which of the following are specific risk factors for health care professionals to become addicted to alcohol or drugs?

D. Work stress and burnout, work injuries, access to drugs.