Exam 5: Practice Questions

Maxwell is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Maxwell has been working for 36 hours straight without eating and has consumed eight double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome

b. Dehydration and caffeine overdose

The nurse instructs the patients spouse about how to cope with the clients anxiety. The nurse determines teaching is successful if the spouse makes which statement? 1. Anxiety is a conscious means of resolving conflict 2. Anxiety represents an unconscious conflict of needs 3. It is important to confront my spouse during periods of anxiety 4. Anxiety is increased by using defense mechanisms

2. Anxiety represents an unconscious conflict of needs

Which statement made by the alcoholic client to the nurse indicates the client has an accurate understanding of the problem? 1. When I can learn to stop after one drink, I will have my problems beat 2. When my family and work problems go away, I wont need alcohol anymore 3. I cant seem to cope with my problems without drinking 4. In my business, most people work hard and drink too much

3. I cant seem to cope with my problems without drinking

The nurse cares for the client with depression who attempts suicide. The nurse understand which is the most likely reason the client attempts suicide? 1. The client is suspicious and mistrustful 2. The client consciously wises to manipulate others 3. The client feels overwhelmed and helpless 4. The client wants to gain attention

3. The client feels overwhelmed and helpless

The nurse knows disulfiram is most likely prescribed for which client? 1. The obese client 2. The dying client 3. The client who is anorexic 4. The client abusing alcohol

4. The client abusing alcohol

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the correct nursing interventions in this situation? Select all that apply. One, some, or all responses may be correct. 1. Provide a protective environment. 2. Assist with personal hygiene. 3. Educate the client about correct body mechanics. 4. Promote activities that reinforce reality. 5. Teach the client's caregiver proper feeding techniques.

1. Provide a protective environment. 2. Assist with personal hygiene. 4. Promote activities that reinforce reality. When caring for an older adult who is in a confused state, the nurse would provide a protective environment, assist with personal hygiene, and promote activities that reinforce reality. If a client is suffering from arthritis, the nurse would educate him or her about correct body mechanics. If the nurse is caring for a client with dementia, then he or she should teach the family caregiver proper feeding techniques.

A client comes to the community mental health center with symptoms of overwhelming anxiety related to a job loss, an impending move, and a sibling being diagnosed with cancer. The client states, "I used to use alcohol to cope, but ever since I've been going to those AA meetings- 2 years now - I have ben able to remain sober." The nurse anticipates the health care provider will order which medication for this client? 1. Chlordiazepoxide 2. Buspirone 3. Alprazolam 4. Diazepam

2. Buspirone

A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? A: Intoxication B: Tolerance C: Withdrawal D: Addiction

B: Tolerance

The nurse instructs the client about phenelzine sulfate. Which client statement indicates to the nurse that further teaching is necessary? 1. I cant wait to eat a hot dog with sauerkraut 2. I'm going to have to get some polycarbophil when I get home 3. I will be playing doubles tennis with my neighbors 4. When I get home, I am going to take my car out for a road trip

1. I cant wait to eat a hot dog with sauerkraut

The nurse expects which medications to be ordered for a client experiencing alcohol withdrawal delirium? 1. Phenobarbital and chlordiazepoxide 2. Disulfiram and chlorpromazine 3. Disulfiram and barbiturates 4. Tricyclics and sedatives

1. Phenobarbital and chlordiazepoxide

The nurse plans care for the client with a history of substance abuse. It is most important for the nurse to select which approach? 1. A structured but permissive setting 2. An environment that increases reality testing 3. A structured, non-permissive setting 4. An environment that decreases stimuli and redirects behavior

3. A structured, non-permissive setting

According to Maslow's hierarchy of needs, which needs are most basic to any client's health maintenance plan? 1. Love and belonging 2. Esteem and recognition 3. Safety and security 4. Self-actualization

3. Safety and security

The psychiatric nurse is presented with a group of clients in the emergency department. Which client requires immediate attention? 1. A young adult client who failed medical school and says, "My pain will be over soon" 2. An adult client who is unable to talk in front of other people due to symptoms of anxiety 3. A middle-age client who hears voices saying to harm others 4. A middle-age client who is anxious after witnessing a murder

1. A young adult client who failed medical school and says, "My pain will be over soon"

The nurse in the mental health clinic understands which foods must be avoided by clients taking phenelzine sulfate? (Select all that apply) 1. Aged cheeses 2. Lunch meats 3. Nuts 4. Leafy green vegetables 5. Tofu 6. Chocolate

1. Aged cheeses 2. Lunch meats 5. Tofu 6. Chocolate

Which initial question by the nurse would be most therapeutic to alleviate the anxiety of the client who is pacing the floor and appears extremely anxious? 1. "What's made you so upset?" 2. "Where would you like to walk with me?" 3. "Shall we sit down to talk about your feelings?" 4. "How would you like to go to the gym to work out?"

2. "Where would you like to walk with me?" The nurse would ask, "Where would you like to walk with me?" The nurse's presence may provide the client with support and a feeling of control. Asking what has upset the client may lead to more anxiety. The client is too distraught to sit; to be therapeutic the nurse would walk with the client, thereby demonstrating concern. The client is in a panic; anger is not the primary emotion and there is no need to work off aggression.

The client is placed on escitalopram 10mg daily. For which adverse effect does the nurse instruct the family to observe? 1. Photophobia 2. Dizziness 3. Epistaxis 4. Hypertensive crisis

2. Dizziness

For a client who is increasingly agitated, which immediate nursing intervention is most likely to increase anxiety? 1. Being assertive 2. Responding early 3. Providing choices 4. Teaching relaxation

4. Teaching relaxation Once the client is agitated, teaching will not be effective. Learning requires attention and participation; failure to learn will increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.

The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? A: Readiness to change and support system B: Current college performance C: Financial ability D: Availability of immediate family to come to meetings

A: Readiness to change and support system

A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? A: Client will return to a predrug level of functioning within 1 week. B: Client will be medically stabilized while in the hospital. C: Client will state within 3 days that they will totally abstain from drugs and alcohol. D: Client will take a leave of absence from college to alleviate stress.

B: Client will be medically stabilized while in the hospital.

Which statement is true regarding substance addiction and medical comorbidity? A: Most substance abusers do not have medical comorbidities. B: There has been little research done regarding substance addiction disorders and medical comorbidity. C: Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D: Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.

C: Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities.

A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A: "It helps your mood so that you don't feel the need to do drugs." B: "It will keep you from experiencing flashbacks." C: "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D: "It helps prevent relapse by reducing drug cravings."

D: "It helps prevent relapse by reducing drug cravings."

A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea

a. Intense nausea b. Diaphoresis d. Confusion e. Dyspnea

The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern

A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low stimulus environment. d. Advocate for at least 3 months of treatment.

b. Manage the patient's withdrawal symptoms well.

Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is: a. Risk for injury/Remains free from injury b. Ineffective denial/Accepts responsibility for behavior c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs d. Risk for suicide/Expresses feelings, plans for the future

c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs

During the evening after a thoracentesis, the client reports anxiety. Which action would the nurse take first? 1. Administer the prescribed analgesic. 2. Listen to the client's breath sounds. 3. Give the client the prescribed as needed lorazepam. 4. Ask the client about specific concerns or worries

2. Listen to the client's breath sounds. Because anxiety is frequently an early manifestation of hypoxemia, the nurse's initial action will be to assess for complications of thoracentesis such as pneumothorax by listening for lung sounds. Administering an analgesic may be indicated if the client states that pain is contributing to anxiety, but would be done after further assessment. Administration of lorazepam may be indicated after the nurse assesses for potential physiological or psychological causes of anxiety. Asking about specific client concerns or worries is indicated once the nurse is sure that physiological factors are not the cause of the anxiety.

Which intervention would the nurse implement for a female client who is unable to open her door because she has run out of the paper towels she uses to avoid touching the doorknob? 1. Explore the feelings that triggered her use of the ritual for opening doors. 2. Encourage her to open the door if she expects to leave for the dining room. 3. Open the door for her and tell her that the staff will try to find more towels. 4. Give her a supply of paper towels and then send her to the dining room for lunch.

4. Give her a supply of paper towels and then send her to the dining room for lunch. The nurse would give the client a supply of paper towels and then send her to the dining room for lunch. Providing paper towels takes into consideration the fact that the client's anxiety will increase if the ritual is interrupted; this allows the client to complete the ritual and encourages her to go to the dining room for lunch. Exploring feelings at this time is inappropriate, because it will increase anxiety and result in the client missing a meal. Having the client open the door without performing the ritual denies the ritual, which will result in an increase in anxiety. Opening the door for the client will precipitate a conflict between completing the ritual and going to the dining room; this conflict will increase anxiety.

Which priority action would the nurse take during the first few hospital days for an adult with schizophrenia who is ungroomed, is withdrawn, and has not spoken to anyone for several days? 1. See that the client bathes and changes clothes daily. 2. Wait and see whether the client approaches the staff. 3. Conduct an admission assessment interview with the client. 4. Seek out the client frequently to spend short periods of time together.

4. Seek out the client frequently to spend short periods of time together. The priority action is to seek out the client frequently to spend short periods of time together. Seeking out the client frequently to spend short periods of time together will help the nurse establish trust without unduly increasing anxiety. Seeing that the client bathes and changes clothes daily is not the priority unless the client is extremely dirty; this client is ungroomed, not dirty. A withdrawn client will usually not approach anyone; the nurse will need to take the initiative. The client's history reveals not speaking to anyone for several days so conducting an admission assessment interview may be futile.

The registered nurse is teaching a nursing student about monoamine oxidase inhibitors (MAOIs). Which statement made by the student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1. "Isocarboxazid is a selective MAO-B inhibitor." 2. "MAO inhibitors are prescribed as adjunct to diphenhydramine." 3. "Hypertensive crisis is a reported adverse effect of MAO inhibitors." 4. "MAO inhibitors are prescribed to clients with Parkinson disease." 5. "Interaction of sympathomimetic medications with MAO inhibitors may cause hypertensive crisis."

1. "Isocarboxazid is a selective MAO-B inhibitor." 2. "MAO inhibitors are prescribed as adjunct to diphenhydramine." Selegiline is a selective MAO-B inhibitor, whereas isocarboxazid is a non-selective MAO-A and MAO-B inhibitor. MAO inhibitors may be contraindicated in clients on diphenhydramine and cetirizine, as they may aggravate depression of the central nervous system. Hypertensive crisis is an adverse effect of MAO inhibitors. They can be prescribed to clients with Parkinson disease. Hypertensive crisis occurs when the sympathomimetic medications are taken with MAO inhibitors.

A primary health care provider prescribes 0.25 mg of alprazolam by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For which side effect of this medication will the nurse monitor the client? 1. Drowsiness 2. Bradycardia 3. Agranulocytosis 4. Tardive dyskinesia

1. Drowsiness Alprazolam, a benzodiazepine, potentiates the actions of gamma-aminobutyric acid, enhances presympathetic inhibition, and inhibits spinal polysynaptic afferent pathways. Drowsiness, dizziness, and blurred vision are common side effects. Alprazolam may cause tachycardia, not bradycardia. Agranulocytosis is usually a side effect of the antipsychotics in the phenothiazine group, not benzodiazepines. Tardive dyskinesia occurs after prolonged therapy with antipsychotic medications; alprazolam is an antianxiety medication, not an antipsychotic.

Which approach would the nurse use for a delusional client who refuses to eat because of a belief that the food is poisoned? 1. Refusing to argue about the food being poisoned 2. Tasting the food in the client's presence 3. Showing the client that other people are eating without being harmed 4. Telling the client that tube feedings will be started if meals are refused

1. Refusing to argue about the food being poisoned The nurse would refuse to argue about the food being poisoned. Clients cannot be argued out of delusions, so the best approach is to not argue about the delusion. Tasting the food in the client's presence is a form of entering into the client's delusions; the client may feel that only a particular part of the meal is free of poison. Showing the client that other people are eating without being harmed is trying to argue the client out of the delusion and this technique will not work. The client can formulate a reason ("They have the antidote") to continue the false belief. Threats are always inappropriate nursing interventions and are illegal. Telling a client that tube feedings will be started if meals are refused is a form of assault.

A client diagnosed with depression is scheduled to bring electroconvulsive therapy (ECT) treatments. It is most important for the nurse to notify the health care provider about which information? 1. The client is being treated for glaucoma. 2. The client's parent had seizures with meningitis. 3. The client has worn dentures for ten years. 4. The client is allergic to shellfish.

1. The client is being treated for glaucoma.

Time for performing rituals has been allowed; however, the client is increasing the frequency and duration, and the rituals are now interfering with sleeping and eating. Which action will the nurse perform first? 1. Allow the rituals because interruption may increase anxiety. 2. Notify the health care provider for a change of medication. 3. Assess for additional or new sources of stress and anxiety. 4. Assist the client to compensate for the ill effects on physical health

3. Assess for additional or new sources of stress and anxiety. First, the nurse would assess for additional or new sources of stress and anxiety that are contributing to the increase in the ritualistic behavior. The nurse would allow the behavior to continue but would notify the provider about assessment findings so that medication or other therapies can be adjusted. To compensate for loss of sleep and nutrition, the nurse can assist the client by giving nutritionally dense snacks and small, frequent meals and encourage the client to rest in between ritualistic behaviors.

A client is brought to the emergency department by family members after taking an overdose of diazepam. The family reports the client has become increasingly depressed and withdrawn during the previous month. Which question is most important for the nurse to ask during the initial interview? 1. Why did you do this to yourself? 2. Can you elaborate on what is bothering you? 3. Exactly how much and when did you take the medication? 4. Did you seriously think of killing yourself?

3. Exactly how much and when did you take the medication?

The nurse sees clients in the adolescent psychiatric clinic. Which client does the nurse see first? 1. The school age client who reports impulsivity and poor attention span 2. The adolescent client who displays frequent loss of temper and argues with teachers 3. The adolescent who wants to be a model and only drinks water and eats vegetables 4. The adolescent client who bullies, threatens, and intimidates others and frequently initiates physical fights

3. The adolescent who wants to be a model and only drinks water and eats vegetables

When a client expresses anxiety about an upcoming surgical procedure, which action would the nurse take first to help decrease anxiety? 1. Administer an anxiolytic medication as prescribed. 2. Request a sleep aid for the night before the client's scheduled surgery. 3. Perform a general history and physical to look for abnormalities that could cause anxiety. 4. Take the client's vital signs and ask questions about the source of the anxiety.

4. Take the client's vital signs and ask questions about the source of the anxiety. The nurse first would take the client's vital signs and assess for the source of the anxiety. It is normal for the client to have an elevated pulse rate when experiencing anxiety, so a full history and physical are not indicated at that point. An anxiolytic or preoperative sleep aid may be helpful but should not be the first action performed by the nurse.

Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy

a. Pupils are dilated d. Extreme anxiety

Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Eileen is so upset."

b. "Gambling activates the reward pathways in my brain."

Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time

c. Tolerance

What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change

d. Not ready to change