Final Exam Practice Questions

The nurse provides home care instructions to the parent of a child with AIDS. Which statement by the parent indicates the need for further teaching? 1. "I will wash my hands frequently" 2. "I will keep my child's immunizations up to date" 3. "I will avoid direct unprotected contact with my child's body fluids" 4. "I can send my child to day care if he has a fever, as long as it is a low grade fever"

"I can send my child to day care if he has a fever, as long as it is a low grade fever"

An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. With knowledge of the most opportunistic infection of children infected with HIV, the nurse assess the infant for which sign? 1. cough 2. liver failure 3. watery stool 4. nuchal rigidity

1. cough sign of pneumocystis pneumonia

The nurse in the ED is caring for a young female victim of sexual assault. The client' physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physical immobile. How should the nurse interpret these behaviors? 1. signs of depression 2. reactions to a devastating event 3. evidence that the client is at high suicide risk 4. indicative of the need for hospital admission

2

A 23 y/o newly married female is taking Depakote and wants to get pregnant. What would the nurse teach her regarding family planning.

Avoid pregnancy while taking this medication

The nurse is caring for a client with major depression? Which is considered a priority assessment? Client's current mood and affect Client's response to medications Client's risk for suicidal behaviors Client's decision-making abilities

Client's risk for suicidal behaviors

A 75 y/o woman is taking an anti-anxiety medication in the morning which makes her dizzy and sleepy 30 minutes later. Which NANDA diagnoses is most appropriate?

High risk for injury

You instruct the patient to avoid eating pepperoni pizza, drinking beer and aged cheese to prevent hypertensive crisis. What class of antidepressant is the patient probably taking?

Monoamine Oxidase Inhibitor (MAOIs)

A male client is taking a 2nd generation antipsychotic and begins to complain of milk leaking from his breast. What medication would you suspect the patient is taking?

Risperidone (Risperdal)

A client is taking Lamictal for bipolar depression. What major adverse effect would the nurse teach the client to monitor for?

Stevens-Johnson Syndrome

The nurse notes a client on Haloperidol x 2 weeks has anorexia, sluggish skin turgor, and a T-101°F. Six hours later, the client has T-103°F, muscle rigidity and a fluctuating B/P. What is the nursing action?

What is discontinue the antipsychotic medication and report the symptoms to the PCP immediately.

Clozapine (Clozaril) is an atypical antipsychotic that is used for treatment resistant Schizophrenia but carries a increased risk for this side effect.

agranulocytosis

Ms. Howard's order is citalopram (Celexa).for her depression and anxiety. Before you administer the first dose, you teach her to observe and report which side effects of the medication? Select all that apply a. drowsiness b. nausea c. agitation d. insomnia e. shuffling gait

b, c, d are all side effects of SSRIs that may cause patient to stop taking medication

Alternating periods of hypomania and depression, but less severe than mania Manic episode Hypomanic episode Depressive episode Cyclothymic disorder

cyclothymic disorder

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse's next priority is to offer which of the following to the client? Legal assistance Crisis intervention A rape support group Medication for disturbed sleep

B

A nurse is assessing a client who is being abused. The nurse would expect to see which symptoms? Select all that apply. A. Assertiveness B. Self-blame C. Alcohol abuse D. Suicidal thoughts E. Guilt

B, C, D, E

When planning interventions for parents who are abusive, the nurse should incorporate knowledge of which factor as a common parental indicator? A. Lower socioeconomic group. B. Unemployment. C. Low self-esteem D. Loss of emotional family attachments.

C

Which labs should be obtained before starting treatment with Valproate for mood stabilization?

Complete Blood Count (CBC), coagulation. liver tests

In the process of dealing with intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish they had been. The nurse should decide that further counseling is needed if the client voices which? A. "I didn't fight him, but I guess I did the right thing because I'm alive. B. "Suicide would be an easy escape from all this pain, but I couldn't do it to myself." C. "I wish they gave the death penalty to all rapists and other sexual predators." D. "I get so angry at times that I have to have a couple of drinks before I sleep."

D

When planning care for a client who is being abused, which measure is most important for the nurse to include? A. Being compassionate and empathetic. B. Teaching the client about abuse and the cycle of violence. C. Explaining to the client about the client's personal and legal rights. D. Helping the client develop a safety plan.

D

The primary care provider (PCP) has recommended to the nurse that the client be discharged to a rehabilitation center for further care. The nurse discusses the recommendation with the family and client, who decide that this is not what they want to do. The nurse's next action is to: Tell the family that this is the PCP's order. Notify the case manager that the family is noncompliant. Discuss available acceptable options with the family. Notify the PCP about the family's decision.

Discuss available acceptable options with the family

A client who attempted suicide 5 years ago with an overdose was brought to the emergency unit 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? Do you have a plan for suicide at this time?" "What major losses have you experienced in the past 6 months?" "Have you experienced any major life crises in the past 6 months?" "Do you feel angry, overwhelmed, or hopeless?"

Do you have a plan for suicide at this time?

Passes an electric current through the brain to induce a seizure. Psychotherapy Cognitive behavioral therapy (CBT) Transcranial magnetic stimulation Electroconvulsive therapy (ECT) Complementary and Alternative therapy

ECT

Which health care delivery system requires patients to be "homebound" in order to receive services? Psychiatry Home Health Care Hospice Chronic Illness

Home Health Care

Which mood stabilizer is the gold standard for the treatment of mania?

Lithium

This medication is a first generation antipsychotic and is currently used to treat intractable hiccups.

Thorazine

This class of anti-pscyhotic medications are used to treat the positive symptoms of psychosis.

Traditional antipsychotics

A 45 y/o executive is entertaining clients at a sports bar. He takes Klonopin (clonazepam) for social anxiety disorder. What beverage should this patient avoid?

alcoholic beverages

What do all these foods have in common: salami; canned figs; bananas; and licorice?

all contain tyramine and should be avoided when taking MAOIs

The dentist may identify signs of this disorder. 1. anorexia 2. bulimia

bulimia

Alteration in mood that is expressed by feelings of sadness, despair, and pessimism; loss of interest in usual activities; change in appetite and sleep patterns; somatic symptoms may be present. Manic episode Hypomanic episode Depressive episode Cyclothymic disorder

depressive episode

Not severe enough to cause marked impairment in social or occupational functioning, does not require hospitalization; no psychotic features Manic episode Hypomanic episode Depressive episode Cyclothymic disorder

hypomanic episode

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

implement limit setting with the client

The adolescent client is starting an SSRI with a black box warning. What signs should you monitor this client for?

suicidal thoughts and behaviors

A client has been taking an antipsychotic medication for 17 years. He has oral movements in this mouth that won't stop with rest. What would you assess for?

tardive dyskinesia

Lithium toxicity can occur in patients taking Lithium. What are some of the symptoms of lithium toxicity? Select all that apply. Vomiting Insomnia Dyspnea Diarrhea Confusion

vomiting, diarrhea, confusion (A, D, &E) symptoms of lithium toxicity include vomiting, diarrhea, confusion, drowsiness, incoordination or ataxia, and T-wave depression on EKG. As lithium levels rise above 2.0mEq/L, ataxia, tinnitus, blurred vision, and severe hypotension might be seen. Acute toxicity may resulting seizure activity, circulatory failure, and death.

The nurse is caring for a client who has been placed on a critical pathway for care following hip surgery. The client asks the nurse why there is a need for this type of care model. What is the best response by the nurse? "Critical pathway is just a new term for the nursing care plan." "Critical pathways give direction to the team caring for you." "Critical pathways make you adhere to the program of care." "Critical pathways ensure that you will get well."

"Critical pathways give direction to the team caring for you."

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

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

The client is on lithium for bipolar disorder. The client's spouse tells the nurse that the client is experiencing more mood swings but the lithium level is 1.3 mEq/L. Which should the nurse tell the spouse to assist with coping? "The part of the brain that controls emotion becomes hypersensitive to stress over time and releases extra neurotransmitters, causing more rapid mood swings." "The body develops a tolerance to the medication, so a higher dose is needed." C. "The sleep-wake cycle is disturbed by the medication." D. "The shorter days in the fall mean there is not enough production of melatonin, which affects mood."

"The part of the brain that controls emotion becomes hypersensitive to stress over time and releases extra neurotransmitters, causing more rapid mood swings."

A client is unwilling to go to church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. avoidant 2. borderline 3. schizotypal 4. obsessive-compulsive

1

PTSD is strongly associated with the functions of the limbic section of the brain. The limbic sections exercises control of the sympathetic part of the central nervous system. Which physiological reactions should you teach Mr. Bagwell to recognize as early indicators of an anxiety response? Select all that apply 1. rapid, shallow breathing 2. excessive sweating 3. slow, uneven heart rate 4. shaking and trembling 5. racing heart rate

1, 2, 4, 5

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. encouraging quiet reading and writing for the first few days 2. identification of physical activities that will provide exercise 3. no socializing activities, until the client asks to participate in milieu 4. a structured program of activities in which the client can participate

4

When working with a group of adult survivors of childhood sexual abuse, dealing with anger and rage is a major focus. Which strategy should the nurse expect to be successful? Select all that apply. A. Using a foam bat while symbolically confronting the abuser. B. Keeping a journal of memories and feelings. C. Directly confronting the abuser. D. Writing letters to the abusers that are not sent. E. Writing letters to the adults who did not protect them that are not sent.

A, B, D, E

What is the best intervention when the nurse assesses that a patient is responding to an auditory hallucination? A. Ask the patient, "Can you tell me what you are hearing?" B. Ask the patient, "Are you afraid of the voice you are hearing?" C. Tell the patient, "Try to ignore the voices you hear." D. Tell the patient, "The voices you hear are not real."

A. Ask the patient, "Can you tell me what you are hearing?"

This class of anti-psychotic medication is used to treat both the positive and negative symptoms of psychosis.

Atypical Antipsychotics

This medication is used in the treatment of muscle spasms of back and neck as well as muscle stiffness and rigidity.

Benztropine (Cogentin)

A 35 y/o male is given an anti-anxiety medication that is classified as a "non-benzodiazepine." Name this medication.

Buspar (Buspirone)

While interviewing a 3-year-old girl who has been sexually abused about the event, which approach would be most effective? A. Describe what happened during the abusive act. B. Draw a picture and explain what it means. C. "Play out" the event using anatomically correct dolls. D. Name the perpetrator.

C

The home health nurse has made a visit to a client who is receiving several therapies by health team members at home for arthritis and postoperative care. Upon return to the home health office, the nurse plans to: Communicate the client's status to the rest of the team. Review the cases for the next day. Report to the manager. Call the client to reinforce teaching.

Communicate the client's status to the rest of the team

This medication is used in the treatment of post-partum depression.

Sertraline (first line) or Paroxetine (alternative)

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: Hypertensive crisis may occur with abrupt withdrawal. Muscle twitching may occur. Parkinson-like symptoms will occur. Symptoms of psychosis are likely to return.

Symptoms of psychosis are likely to return.

During a psychosocial assessment, the client tells the nurse, "My husband promised me he will stop abusing alcohol, so he can take me out to a nice dinner." The nurse recognizes that the client's situation is in which phase of the cycle of violence? First phase Second phase Third phase Fourth phase

Third Phase

This class of antidepressants should be used with caution. It can also cause orthostatic hypertension and blurred vision

Tricyclic Antidepressants (TCAs)

Amenorrhea is common with 1. anorexia 2. bulimia

anorexia

When a client with paranoid schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the client? Sedation and muscle stiffness Sweating, nausea, and diarrhea Mild fever, sore throat, and skin rash Headache, watery eyes, and runny nose

sedation and muscle stiffness

The nurse is working with a woman 4 weeks after childbirth who is experiencing mild depression. The woman's partner asks the nurse whether there is anything he can do to help the new mother during this transition. The nurse suggests which action? Take the client to be admitted to the psychiatric facility. Take the mother out for dinner once a week. Give the mother extra tasks so she won't think about depression. Send the mother to her mother's home for the duration.

take the mother out to dinner once a week The partner is encouraged to be supportive of the new mother and to find ways to decrease her stress and provide her with some pleasurable activities. (A). This client does not need to be in the hospital. (C ). Giving the mother more work may deepen the symptoms. (D). The couple needs to work this out together and not send the mother away, which could lower her self-esteem.

Ms. Howard is becoming increasingly anxious after a phone call with her sister. Which nursing interventions will you use to help her cope with the situation. Select all that apply 1. use a firm and authoritative voice 2. take her to the community room 3. focus her attention on a receptive task 4. maintain a calm demeanor 5. use short, simple sentences

1, 3, 4, 5

The attending health care provider decides to hospitalize Ms. Howard for severe anxiety and to treat her cracking and bleeding hands. As the admitting nurse, your plan of care needs to focus on which essential features of obsessive compulsive disorder? Select all that apply 1. fear 2. immediately stopping compulsive behaviors 3. ineffective coping 4. paranoia 5. uncontrollable urge to perform certain acts

1,3,5

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1. Increase socialization of the client with peers 2. avoid using a whisper voice in front of the client 3. Begin to educate the client about social supports in the community 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2

The attending health care provider decides to start Ms. Howard on an antidepressant to treat her chronic depression. What teaching points about SSRIs would you make? 1. SSRIs have no serious side effects when combined with other medications 2. SSRIs are quick acting and immediately effective 3. SSRIs inhibit the reuptake and slow down the deactivation of the neurotransmitter dopamine. 4. SSRIs should be tapered off gradually when discontinued.

4

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. Select the response that accurately describes genetics and schizophrenia. One single gene is responsible for producing schizophrenia. There is strong evidence that environmental factors do not affect the risk of developing schizophrenia. The chance of monozygotic (identical) twins both having schizophrenia is 100%, thus demonstrating the high level of genetic influence in schizophrenia. An individual has an 8%-13% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

An individual has an 8%-13% chance of being diagnosed with schizophrenia if a sibling or parent has the disorder.

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

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

A client admitted to the hospital for a recent suicide attempt has been taking prescribed antidepressants 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? Are you still having thoughts of suicide?" "Are you willing to sign a 'no-harm' contract before you leave?" "How would you rate your mood on a scale of 1 to 10?" "How can we be sure you won't hurt yourself when you go home?"

Are you still having thoughts of suicide?"

A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, "He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them." Which of the following is the most crucial information for the nurse to determine? A. The type and extent of abuse occurring in the family. B. The potential of immediate danger to the client and her children. C. The resources available to the client. D. Whether the client wants to be separated from her husband.

B. The potential of immediate danger to the client and her children.

A client is taking Lithium and needs to monitor his blood values. Which three lab values are most important to monitor?

BUN, Creatinine, Sodium

What class of medications are considered tranquilizers and used to treat anxiety, panic, seizures, and alcohol withdrawal

Benzodiazepines

In working with a rape victim, the nurse considers which as most important? A. Continuing to encourage the client to report the rape to the legal authorities. B. Recommending that the client resume sexual relations with her partner as soon as possible. C. Periodically reminding the client that she did not deserve and did not cause the rape. D. Telling the client that the rapist will eventually be caught, put on trial, and jailed.

C

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by an abuser? A. Tying the child down. B. Bribery with money. C. Coercion as a result of a trusting relationship. D. Asking the child's consent for sex.

C

Helps clients identify patterns of irrational thinking and find ways to replace them with more logical and fact-based patterns of thinking Psychotherapy Cognitive behavioral therapy (CBT) Transcranial magnetic stimulation Electroconvulsive therapy (ECT) Complementary and Alternative therapy

CBT

Used for depression, fatigue, insomnia, and anxiety Psychotherapy Cognitive behavioral therapy (CBT) Transcranial magnetic stimulation Electroconvulsive therapy (ECT) Complementary and Alternative therapy

Complementary and Alternative therapy

This category of drugs combined with tyramine rich foods can precipitate this problem. Name the category and the problem.

MAOI and hypertensive crisis

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. Of the following intervention strategies, which strategy must be initiated immediately? Monitor the client's behavior. Identify the client's thought process that leads to this behavior. Help the client to identify why the client demonstrates this behavior. Teach appropriate interpersonal skills to the client.

Monitor the client's behavior

The nurse is caring for a woman who is 1-day postpartum, has a history of depression, and plans to breastfeed her baby. What would the nurse expect the physician to order? Fluoxetine (Prozac) Admission to the psychiatric unit Consult with child protective services Referral to a mental health professional for follow-up

Referral to a mental health professional for follow-up

When performing collaborative health care, the nurse must implement which of the following? Assume a leadership role in directing the health care team. Rely on the expertise of other health care team members. Be physically present for the implementation of all aspects of the care plan. Delegate decision-making authority to each health care provider.

Rely on the expertise of other healthcare team members

A patient starts take Elavil (amtriptylline). After one week, the patient complains of flu symptoms: T102.4, HR 115, BP 158/105 and shivers and a headache. Which diagnosis would you expect?

Serotonin Syndrome

Therapy targets the right prefrontal cortex in manic episodes with rapid action onset of one to two weeks Psychotherapy Cognitive behavioral therapy (CBT) Transcranial magnetic stimulation Electroconvulsive therapy (ECT) Complementary and Alternative therapy

Transcranial magnetic stimulation

These combinations can precipitate a serotonin syndrome. Name two combinations.

What is antidepressants and St. John's Wort and/or OTC cold and cough medication

A client with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. "How long has the voice been directing your behavior?" "Does what the voice tells you to do frighten you?" "Do you recognize the voice speaking to you?" "What is the voice telling you to do?"

What is the voice telling you to do

The ED nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. information regarding shelters 2. instructions regarding calling the police 3. instructions regarding self defense classes 4. explaining the importance of leaving the violent situation

information regarding shelters

Alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking/speaking; can occur as a biological or psychological disorder, or as a response to substance use or a general medical condition Manic episode Hypomanic episode Depressive episode Cyclothymic disorder

manic episode

The nurse is caring for a client experiencing a major depressive episode. The nurse monitors the client for signs of urinary retention and constipation. To what can these problems be attributed? Inadequate dietary and fluid intake Psychomotor retardation and medication Lack of exercise Poor dietary choices

psychomotor retardation and medication The only option that can cause urinary retention and constipation is psychomotor retardation and medication. Medication therapy with tricyclic antidepressants is known to cause urinary retention and constipation. Psychomotor retardation is characterized by noticeably slowed body movements and a subsequent slowing of all body processes, which can lead to urinary retention and constipation. (A, C, &D). Can cause constipation, but not urinary retention.

Can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing. Psychotherapy Cognitive behavioral therapy (CBT) Transcranial magnetic stimulation Electroconvulsive therapy (ECT) Complementary and Alternative therapy

psychotherapy

A 73-year-old client is in the hospital for pneumonia for the third time in six months. During the nursing history, the nurse discovers that the client has few financial resources, lives alone, and has not received needed immunizations. To provide excellence in care, the nurse should: Request consultations with other disciplines. Recommend that the client remain in the hospital until well. Request an order from the physician for long-term care. Tell the client of the need to move to long-term care.

request consultations with other disciplines

A patient taking Ativan (Lorazepam) 6mg daily for 5 years wants to stop "cold turkey". Which life threatening concerns should you teach?

seizure precautions

This class of medications primarily increase the blood concentration of serotonin?

selective serotonin uptake inhibitors (SSRIs)

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened? 1. encourage the mother to breast-feed soon after birth 2. support the mother in her reaction to the newborn infant 3. Tell the mother that it is important to hold the newborn infant 4. Document a complete account of the mother's reaction on the birth record

support the mother in her reaction to the newborn infant

Susan has been taking Lithium (Eskalith) for several years. Which are common side effects of lithium? Select all that apply. Thirst Nausea Constipation Tremor Dizziness

thirst, nausea, tremor, dizziness