HESI RN MENTAL HEALTH HESI REVIEW - MULTIPLE CHOICE, HESI MH Practice

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32.TOOL assessment

- cut down on your drinking, people annoyed you, felt bad or guilty about your drinking, drink first thing in the morning hangover (Eye- opener)

38. Angry pt because of coworkers, then a car accident, what is the nurse best response?

-"several things made you angry?"

25. recurrent negative symptoms of chronic schizophrenia and medication risperdal. walks laterally contracted position, something has made his body contort -

-administer the prescribed anticholinergic benztropine (cogentin) for dystonia

36. Client overdose on acetaminophen (Tylenol). What should the nurse monitor next?

-check for more narcotic effects

A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care?

-delay business decisions until his mania subsides

20. postpartum depression Sign & Symptoms (3) -

-distrubed sleep, sadness, poor concentration

12. teenaged girl self induced vomiting

-frequency of binging and purging behaviors

31. Client makes a statement I feel like im going to die, what level of Anxiety is it?

-moderate anxiety

18. adolescent teen interrupts group about pets at home?

-redirect him to read from materials

26. depression remains in bed most of the day, declines activities and refuses meals

-refusal to address nutritional needs

30. Psychomotor retardation, hypersomnia, and amotivation; what nursing intervention?

-teach client to have daily structured activities

24. client who refuses antipsychotic medication disrupt group activities nurse decides client needs constant observation based on?

-wanders into client's room

28. patient taking sertraline (zoloft) for postpartum depression, nursing teaching

-contact healthcare provider if having suicidal thoughts (black box warning)

16. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

-establish trust by providing a calm, safe environment

ECT therapy is not working, patientt is non responsive to treatment, what question should the nurse ask?

-have you taken erectile dysfunction meds

13. Pt is getting oreiented to the unit and replies "there are no TVs in the room" What is the nurse's best respond?

-it is important to be out of your room and talking to others

8. A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take?

-plan a list of activities to be carried out daily

A client is preparing to attend at Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed. 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others

3, 1, 2, 5, 4

A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: A) "I no longer feel that I deserve the beatings my husband inflicts on me." B) "My attendance at the meetings has helped me to see that I provoke my husbands violence." C) "I enjoy attending the meetings because they get me out of the house and away from my husband." D) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

A) "I no longer feel that I deserve the beatings my husband inflicts on me."

A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects? A) "If I eat too many fruits, I'll get constipated." B) I need to take the medicine with food to avoid nausea." C) "I have to get up slowly so I don't get dizzy." D) "Sometimes I have to push myself because I'm sleepy."

A) "If I eat too many fruits, I'll get constipated."

A client diagnosed with paranoid schizophrenia is still withdrawn, unkept, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The nurse should tell the health aide: A) "Prolixin is the most effective with positive symptoms of schizophrenia." B) "The client will be less withdrawn and unmotivated when the Prolixin takes effect." C) "The client's Prolix dose probably needs to be increased again." D) "Lack of motivation is a common side effect of the Prolixin."

A) "Prolixin is the most effective with positive symptoms of schizophrenia."

A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The nurse describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply. A) A common goal is shared by all members B) Members are required to remain anonymous C) The leader is a professional mental health care provider D) Attendance must be prescribed by the health care provider E) The program is designed to provide support and bring about personal change F) The group is composed of individuals who are experiencing similar problems

A) A common goal is shared by all members E) The program is designed to provide support and bring about personal change F) The group is composed of individuals who are experiencing similar problems

A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the nurse include in the plan of care? Select all that apply. A) Avoid laughing when near the client B) Whisper when communicating near the client C) Increase socialization of the client among his peers D) Have the client sign a written release of information form E) Provide food items that are in containers that need to be opened F) Begin to educate the client about social supports in the community

A) Avoid laughing when near the client E) Provide food items that are in containers that need to be opened

Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. A) Communicate expected behaviors to the client B) Ensure that the client knows that he or she is not in charge of the nursing unit C) Assist the client in identifying ways of setting limits on personal behaviors D) Follow through about the consequences of behavior in a non punitive manner E) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups F) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior

A) Communicate expected behaviors to the client C) Assist the client in identifying ways of setting limits on personal behaviors D) Follow through about the consequences of behavior in a non punitive manner F) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior

A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement? A) Encourage the client to actively participate in assigned activities on the unit. B) Place a lock on the client's closet. C) Ignore the client's paranoid ideation to extinguish these behaviors. D) Explain to the client that his suspicions are false.

A) Encourage the client to actively participate in assigned activities on the unit

A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Ability) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply. A) Headaches that will subside in a few weeks B) Transient mild anxiety C) Insomnia D) Torticollis E) Pill rolling movements

A) Headaches that will subside in a few weeks B) Transient mild anxiety C) Insomnia

An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? A) Information regarding shelters B) Instructions regarding calling the police C) Instructions regarding self-defense classes D) Explaining the importance of leaving the violent situation

A) Information regarding shelters

An outpatient clinic who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103, and trouble breathing on day 3. The nurse interest these findings as indicating which of the following. A) Neuroleptic Malignant Syndrome B) Tardive dyskinesia C) Extrapyramidal adverse effects D) Drug-induced parksonism

A) Neuroleptic Malignant Syndrome

A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select all that apply. A) Use open-ended questions to encourage client dialogue B) Offer opinions about the necessity for adequate nutrition C) Focus on the client's self-disclosure about food preferences D) Identify the reasons the client has for not wanting to eat E) Offer the client food in closed containers, such as in cans that have to be opened

A) Use open-ended questions to encourage client dialogue E) Offer the client food in closed containers, such as in cans that have to be opened

The nurse is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention? A) Very high temperature B) Muscular rigidity C) Tremors D) Altered consciousness

A) Very high temperature

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors ask the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? A. "I can not discuss any patient situation with you." B. "If you want to know about Mary, you need to ask her yourself." C. "Only because you're worried about a friend, I'll tell you that she is improving." D. "Being her friend, you know she is having a difficult time and deserves her privacy."

A. "I can not discuss any patient situation with you."

A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. "You appear to be talking to someone I do not see." B. "Please describe what you are seeing." C. "Why do you continually look in the corner of this room?" D. "If you hum a tune, the voices may not be so distracting."

A. "You appear to be talking to someone I do not see."

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem. A. Acute confusion B. Ineffective community coping C. Disturbed sensory perception D. Self-care deficit

A. Acute confusion

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem? A. Acute confusion. B. Ineffective community coping C. Disturbed sensory perception. D. Self-care deficit.

A. Acute confusion

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression. C. Begin planning for the clients discharge. D. Encourage verbalization of feelings.

A. Allow the client to rest and sleep

A. Allow the client to rest and sleep.

Which nursing actions are likely to help promote the self-esteem of a male client with modern depression? select all that apply A. Ask the client what his long term goals are. B. Discuss the challenges of his medical condition. C. Include the client in determining treatment protocol. D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns.

A. Ask the client what his long term goals are. D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns.

The mother of an 8-month-old infant with profound mental and physical disabilities tells The RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? A. Ask the mother if she has ever thought about harming herself or her child. B. Reassure the mother that her child will achieve some growth and development milestones. C. Determine if the mother has other children who do not have developmental disabilities. D. Encourage the mother to write thoughts and feelings in journal

A. Ask the mother if she has ever thought about harming herself or her child.

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter of fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety.

A. Assist the client in developing alternative coping skills.

A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg. B. Pulse rate of 68-78 BPM. C. Temperature of 99.5-99.7 F. D. Respiration rate of 24 breaths per minute.

A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportations. C. Attempt to persuade the patient to stay for only a few more days. D. Tell the patient that leaving would likely result in an involuntary commitment.

A. Contact the patient's health care provider (HCP).

A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? A. Denial B. Projection C. Rationalization D. Intellectualization

A. Denial

A patient admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting. "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the patient implementing? A. Denial B. Projection C. Regression D. Rationalization

A. Denial

A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition? A. Dissociative disorder. B. Obsessive-compulsive disorder. C. Panic disorder. D. Post-traumatic stress syndrome.

A. Dissociative disorder

A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Do not take any over the counter meds. B. Eat a high carb, low fat, low protein diet. C. Call the crisis hotline if feeling lonely. D. Avoid exposure to large crowds.

A. Do not take any over the counter meds.

A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem admission to the psychiatric unit? A. Ineffective sexual patterns B. Impaired environmental interpretation C. Disturbed sensory perception D. Compromised Family Coping

A. Ineffective sexual patterns

A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? A. Ineffective sexual patterns. B. Impaired environmental interpretation. C. Disturbed sensory perception. D. Compromised family coping

A. Ineffective sexual patterns

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states" I don't need to be here," and tells the RN that she believes that the T.V. talks to her. The RN should document these assessment statements in which section of the mental status exam? A. Insight and judgement. B. Mood and affect. C. Remote memory. D. Level of concentration.

A. Insight and judgement.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loid voice to talk to the client. D. Remains at a distance of 4 feet from the client.

A. Is attempting to physically restrain the patient.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loud voice to talk to the client. D. Remains at a distance of 4 feet from the client.

A. Is attempting to physically restrain the patient.

The RN on the evening shift receives report that a client is scheduled for Electroconvulsive Therapy in the morning. Which intervention should the RN implement the evening before the scheduled ECT? A. Keep client NPO after midnight B. Hold all bedtime meds C. Implement elopement precautions D. Give the client an enema at bedtime

A. Keep client NPO after midnight

When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission C. Supply the patient with written information about their mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed.

A. Monitor closely for harm to self or others.

A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? A. Not sleeping for several days. B. Wishing to be with spouse. C. Lack of interest in usual activities. D. Eating very little.

A. Not sleeping for several days.

A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? A. Offer the client a safe place to relax before interviewing her. B. Ask the client to describe why she is being stalked. C. Recommend that the client talk with a social worker. D. Assure the client that the HCP will see her today.

A. Offer the client a safe place to relax before interviewing her.

A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse nots a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take? A. Pay close attention and document the nonverbal messages B. Ask the client's husband to interpret the discrepancy C. Ignore the nonverbal behavior and focus on the client's verbal messages D. Integrate the verbal and nonverbal messages and interpret them as one

A. Pay close attention and document the nonverbal messages

A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. What action does the RN take? A. Pay close attention and document the nonverbal messages. B. Ask the client's husband to interpret the discrepancy. C. Ignore the nonverbal behavior and focus on the client's verbal messages. D. Integrate the verbal and nonverbal messages and interpret them as one.

A. Pay close attention and document the nonverbal messages.

The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP? A. Potassium level of 2.9 mEq/dl. B. Blood pressure of 110/70 mmHg. C. WBC of 10,000mm^3. D. Body mass index of 21.

A. Potassium level of 2.9 mEq/dl.

A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: A. Provide safety for the client and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff in caring for the client in a controlled environment D. Offer the client a less stimulated area to calm down and gain control

A. Provide safety for the client and other clients on the unit

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action is needed since polydipsia is a common side effect. D. Tell the client that drinking from the faucet is not allowed.

A. Report the client's serum lithium level to the HCP.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting

A. Restatement

The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? (Select all that apply) A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval

A. Restating B. Listening D. Maintaining neutral responses E. Providing acknowledgment and feedback

A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior.

A. Stay quietly with the patient

After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations

A. The nontherapeutic technique of giving approval

A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the nurse use to encourage the patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition

A. Using open-ended questions and silence

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client's rooms. The RN decides that the client needs constant observation based on which of these assessment findings? A. Wanders into the clients rooms. B. Refuses antipsychotic medications. C. Talks with nonsensical words. D. Disrupts group activities.

A. Wanders into the clients rooms.

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test.

A. Weight gain of 75 lbs

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to takingolanzapine? A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test.

A. Weight gain of 75 lbs.

A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the nurse is most important? A) "How do you think you will be punished?" B) "Please tell staff when you think you need to punish yourself." C) "What exactly do you think you have done to be punished?" D) "Let's talk about your strengths"

B) "Please tell staff when you think you need to punish yourself."

A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? A) Do you have problems with hallucinations? B) Are you ever alone when you hear the voices? C) Has anyone in your family had hearing problems? D) Do you see things that others cannot see?

B) Are you ever alone when you hear the voices?

A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: A) On an empty stomach B) At the same time each evening C) Evenly spaced around the clock D) As needed when the client complains of depression

B) At the same time each evening

The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, "Why isn't he eating? He's still talking about his food being poisoning." With of the following appraisals by the nurse is most accurate? A) The wife's inquiry is reasonable B) Education about her husband's medication is needed C) Her expectations of her husband are realistic D) An increase in the client's medication is needed

B) Education about her husband's medication is needed

A nurse is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? A) Cardiovascular symptoms B) Gastrointestinal dysfunctions C) Problems with mouth dryness D) Problems with excessive sweating

B) Gastrointestinal dysfunctions

The nurse should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply. A) The medical diagnosis of the client B) Individualized goals and objectives C) Attendance at group therapy sessions D) Self-care measures to improve hygiene E) Interruption of all compulsive behaviors

B) Individualized goals and objectives C) Attendance at group therapy sessions D) Self-care measures to improve hygiene

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? A) Altered thought processes. B) Moderate levels of anxiety. C) Inadequate social support. D) Altered health maintenance.

B) Moderate levels of anxiety.

On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity? A) Clean the unit kitchen cabinets. B) Participate in a group quilting project. C) Watch television in the activity room. D) Bake a cake for a resident's birthday.

B) Participate in a group quilting project

A nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: A) Witnessing a murder B) The death of a loved one C) A fire that destroyed the client's home D) A recent rape episode experienced by the client

B) The death of a loved one

When caring for a client who has overdosed on PCP, the nurse should be especially cautious about which of the following client behaviors? A) Visual hallucinations B) Violent behavior C) Bizarre behavior D) Loud screaming

B) Violent behavior

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will A) outline methods for managing anger. B) control impulsive actions toward self and others. C) verbalize feelings when anger occurs. D) recognize consequences for behaviors exhibited.

B) control impulsive actions toward self and others.

A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide? A. "Let's go ask another RN if this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one of your children." D. "I know that you don't have 20 children."

B. "My name tag shows that I am a RN here."

A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide? A. "Let's go ask another RN is this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one if your children." D. "I know that you don't have 20 children."

B. "My name tag shows that I am a RN here."

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. "What occurred prior to the rape, and when did you go to the emergency department?" B. "What would you like to talk about?" C. "I notice you seem uncomfortable discussing this." D. "How can we help you feel safe during your stay here?"

B. "What would you like to talk about?"

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression? A. Feelings of frustration. B. A sense of loss C. Poor self-esteem. D. A lack of intimate relationships.

B. A sense of loss

Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to His care and is belligerent when another RN is assigned. What action should the charge RN implement? A. Reassure the client that his request will be met whenever possible. B. Advise the client that assignments are not based on the client's request. C. Ask the client to explain why he constantly requests the RN. D. Encourage the client to verbalize his feelings about the RN.

B. Advise the client that assignments are not based on the client's request.

While setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? A. Discuss the client's feeling when he responds. B. Allow the client to identify the way he interacts. C. Initiate a non-threatening conversation with the client. D. Dialog about the ineffectiveness of his interactions.

B. Allow the client to identify the way he interacts.

A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Pulse rate 68-78 bpm B. BP readings of 90/62 mmHg to 92/58 C. Temperature of 99.5-99.7 F D. Respiration rate of 24 bpm

B. BP readings of 90/62 mmHg to 92/58

The LPN/LVN calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? (Select all that apply) A. Libel B. Battery C. Assault D. Slander E. False Imprisonment

B. Battery C. Assault E. False Imprisonment

The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? A. Lithium. (Lithotabs) B. Benzotropine (Cogentin). C. Alprazolam (Xanax). D. Magnesium (Milk of Magnesia).

B. Benzotropine (cogentin)

Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? A. Client's medication history includes the frequent use of antidepressants. B. Describe self as a social drinker who drinks alcoholic beverages daily. C. Reports difficulties with short term memory since traumatic brain injury. D. Medical history includes that the client was recently sexually assaulted.

B. Describe self as a social drinker who drinks alcoholic beverages daily.

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? A. Purchase a gun to use for protection B. Establish a code with family and friends to signify violence. C. Plan an escape route to use if the abuser blocks the main exit. D. Have a big ready that has extra clothes for self and children.

B. Establish a code with family and friends to signify violence. C. Plan an escape route to use if the abuser blocks the main exit. D. Have a big ready that has extra clothes for self and children.

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply) A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

B. Establish a code with family and friends to signify violence. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

B. Establish a code with family and friends to signify violence. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A. Encourage substitution of positive thoughts for negative ones B. Establish trust by providing a calm, safe environment C. Progressively expose the client to larger crowds D. Encourage deep breathing when anxiety escalates in a crowd

B. Establish trust by providing a calm, safe environment

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A. Encourage substitution of positive thoughts and negative ones. B. Establish trust by providing a calm, safe environment. C. Progressively expose the client to larger crowds. D. Encourage deep breathing when anxiety escalates in a crowd.

B. Establish trust by providing a calm, safe environment.

A high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent? A. National percentile of weight and height. B. Frequency of bingeing and purging behaviors. C. Perceptions of family and social relationships. D. School grades and extracurricular activities.

B. Frequency of bingeing and purging behaviors.

A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? A. When was the last time you drank alcoholic beverage? B. Have you taken any medications for erectile dysfunction? C. Are you having any other sexual dysfunctions or problems? D. Do you have a history of angina or high blood pressure?

B. Have you taken any medications for erectile dysfunction?

A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority? A. Identify support systems in the community that may be helpful. B. Help the client feel safe to decrease anxiety. C. Ask the client to describe coping strategies that were helpful in the past. D. Encourage the client to verbalize anxiety related to event.

B. Help the client feel safe to decrease anxiety.

The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members B. Helping clients identify areas of problem in their lives C. Discussing ways to use new coping skills learned D. Clarifying the nurse's role and clients' responsibilities

B. Helping clients identify areas of problem in their lives

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy.

B. I am here because the police thought I was doing something wrong.

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatricunit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy.

B. I am here because the police thought I was doing something wrong.

A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care? A. Implement behavioral modification therapy. B. Initiate caloric and nutritional therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend.

B. Initiate caloric and nutritional therapy.

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam/ A. Level of concentration. B. Insight and judgement. C. Remote memory. D. Mood and affect.

B. Insight and judgement

The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? A. Hold all bedtime medications. B. Keep the client NPO after mid-night. C. Implement elopement precautions. D. Give the client an enema at bedtime.

B. Keep the client NPO after mid-night.

The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? A. Planning short-term goals B. Making appropriate referrals C. Developing realistic solutions D. Identifying expected outcomes

B. Making appropriate referrals

A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, "I feel like I am going to die," which nursing problem should the nurse include in this client's plan of care? A. Mood disturbance B. Moderate anxiety C. Altered thoughts D. Social isolation

B. Moderate anxiety

A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, "I feel like I'm going to die". Which nursing problem should the RN include in this client's plan of care? A. Mood disturbance. B. Moderate anxiety. C. Altered thoughts. D. Social isolation.

B. Moderate anxiety.

A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? A. Encourage oral fluids. B. Monitor vital signs. C. Keep the room dark. D. Apply ice to his tongue.

B. Monitor vital signs

A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R

B. O rationale: The acronym SOLER includes: A: (S)itting squarely facing the client B: (O)pen posture when interacting with the client C: (L)eaning forward toward the client D: (E)stablishing eye contact E: (R)elaxing

A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take? A. Report the behavior to the next shift. B. Offer to play a game of cards with the client. C. Document the behavior in the chart. D. Plan to talk with the client the next day.

B. Offer to play a game of cards with the client.

A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan-seared catfish. B. Peperoni pizza. C. Deep fried shrimp. D. Beef trips with gravy.

B. Peperoni pizza.

Male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior. When admitting the client to the unit, which action is most important for the nurse to take? A. Ask the client about his recent substance use B. Perform a mental status exam C. Determine the number of previous hospitalizations D. Assess the client from head-to-toe

B. Perform a mental status exam

The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing? A. Provide detailed thorough explanations when cleansing wound. B. Perform the dressing change in a non-judgmental manner. C. Ask in a non-threatening manner why the client cut own abdomen. D. Request another staff member assist with the dressing change.

B. Perform the dressing change in a non-judgmental manner.

The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation? A. A summary of the client's feelings. B. Photographs. C. A general description. D. A client's significant other's statement.

B. Photographs.

A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? A. Decreased bowel movements. B. Presence of a dry mouth. C. Decreasing hand tremors. D. Increased mouth movements.

B. Presence of a dry mouth.

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? A. Notify the physician immediately and force fluids. B. Prior to giving the next dose, notify the physician of the symptoms. C. Record the symptoms and continue medication as prescribed. D. Hold the medication and refuse to administer additional amounts of the drug.

B. Prior to giving the next dose, notify the physician of the symptoms.

A male client approaches the RN with an angry expression on his face and raises his voice, saying "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism? A. Denial. B. Projection. C. Rationalization. D. Splitting.

B. Projection

A male client approaches the nurse with an angry expression on his face and raises his voice saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism? A. Denial B. Projection C. Rationalization D. Splitting

B. Projection

A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take? A. Encourage the client to stay in the hospital so the client does not have to be homeless. B. Provide the client with medication if the client presents an imminent risk to self and others. C. Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. D. Describe to the client treatment options provided at the community mental health clinics.

B. Provide the client with medication if the client presents an imminent risk to self and others.

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care? A. Relax and reduce the amount of effort to solve the problem B. Recall methods that were most successful in the past C. reach out to family and friends about feelings of abandonment D. turn to other activities to take one's mind off of the issues

B. Recall methods that were most successful in the past

After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take? A. Refer the student to a psychiatrist for further discussion. B. Recommend assignment to the receptionist's office. C. Suggest that student work in the athletic department. D. Determine the parent's opinion of the work assignment.

B. Recommend assignment to the receptionist's office.

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? A. Admit to others that he is a substance abuser. B. Remain alcohol free for 12 hours prior to first dose. C. Attend monthly meetings of alcoholics anonymous. D. Completely sustain from heroin or cocaine use.

B. Remain alcohol free for 12 hours prior to first dose.

The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A. Completely abstain from heroin or cocaine use. B. Remain alcohol free for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous. D. Admit to others that he is a substance user.

B. Remain alcohol free for 12 hours prior to the first dose.

A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? A. Deficient diversional activity related to excess energy level. B. Risk for other related violence related to disruptive behavior. C. Risk for activity intolerance related to hyperactivity. D. Disturbed personal identity related to grandiosity.

B. Risk for other related violence related to disruptive behavior.

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian B. Sleep at least 6 hours a night C. Understands the purpose of the medication regimen D. Describes the reason for hospitalization

B. Sleep at least 6 hours a night

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian. B. Sleep at least 6 hours a night. C. Understands the purpose of the medication regimen. D. Describes the reasons for hospitalization.

B. Sleep at least 6 hours a night.

A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client's plan of care? A. Risk for suicide. B. Sleep deprivation. C. Situational low self-esteem. D. Social isolation.

B. Sleep deprivation.

A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A. Provide education on methods to enhance sleep. B. Teach the client to develop a plan for daily structured activities. C. Suggest that the client develop a list of pleasurable activities. D. Encourage the client to exercise.

B. Teach the client to develop a plan for daily structured activities.

An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite. B. The emotional quality of his attitude C. His level of activity. D. The interactions he has with others.

B. The emotional quality of his attitude

An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite B. The emotional quality of his attitude C. His level of activity D. The interactions he has with others

B. The emotional quality of his attitude

A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: A. Move the client next to the nurse's station B. Use an indirect light source and turn off the television C. Keep the television and a soft light on during the night D. Play soft music during the night and maintain a well-lit room

B. Use an indirect light source and turn off the television

When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take? A. Tell him to take the medication then verify the dosage at the next healthcare team meeting. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Explain to the client that the dosage has been changed.

B. Withhold the medication until the dosage can be confirmed.

A male college student visits the student health center for his annual physical examination. His vital signs and blood glucose...range. His height is 6 feet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain? A. 24-hour nutritional history B. body mass index C. basal metabolic rate D. complete blood count

B. body mass index

A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family? A. Despite his illness, the client should be able to live away from home B. his serum lithium levels should be routinely evaluated C. he should plan to participate in group or individual therapy while at college D. he should be aware of the symptoms of his illness

B. his serum lithium levels should be routinely evaluated

9. The nurse is preparing medications for a client with disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Benztropine (Cogentin)

A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? A) "You need to try and be realistic. The rape did not just occur." B) "It will take some time to get over these feelings about your rape." C) "Tell me more about the incident that causes you to feel like the rape just occurred." D) "What do you think that you can do to alleviate some of your fears about being raped again?"

C) "Tell me more about the incident that causes you to feel like the rape just occurred."

A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: A) "With whom do you live?" B) "Who is available to help you?" C) "What leads you to seek help now?" D) "What do you usually do to feel better?"

C) "What leads you to seek help now?"

The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital? A) Determine if the client attends a support group weekly. B) Hold all antidepressant medications until further notice. C) Ask the client if he takes St. John's Wort routinely. D) Have the client describe any recent changes in mood.

C) Ask the client if he takes St. John's Wort routinely.

Which of the following liquids should the nurse administer to a client who is intoxicated on PCP to hasten excretion of the chemical? A) Water B) Milk C) Cranberry juice D) Grape juice

C) Cranberry juice

A nurse is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. A) Discourage reminiscing B) Make decisions for the family C) Encourage expression of feelings, concerns, and fears D) Explain everything that is happening to all family members E) Touch and hold the client's or family member's hands if appropriate F) Be honest and let the client and family know that they will not be abandoned by the nurse

C) Encourage expression of feelings, concerns, and fears E) Touch and hold the client's or family member's hands if appropriate F) Be honest and let the client and family know that they will not be abandoned by the nurse

A moderatley depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: A) Suggesting a reduction of medication B) Allowing increased "in-room" activities C) Increasing the level of suicide precautions D) Allowing the client off-unit privileges as needed

C) Increasing the level of suicide precautions

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by: A) Engaging in immoral acts B) Always reinforcing self-approval C) Observing rigid rules and regulations D) Having the need always to make the right decision

C) Observing rigid rules and regulations

An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and instance, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as the cause of the mother's behavior and what action should she suggest? A) The client is manic and may need a sleeping pill B) The client is experiencing a medication interaction and should go to the ED C) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately D) The client is overcome by grief and probably needs an antidepressant

C) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately

A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his A) early childhood experiences involving authority issues. B) anger about being hospitalized. C) low self-esteem. D) phobic fear of food.

C) low self-esteem.

A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is A) regressing to an earlier behavior pattern. B) sublimating her anger. C) projecting her feelings onto the nurse. D) suppressing her fear.

C) projecting her feelings onto the nurse.

Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? A. "Autonomy is the fundamental right of each and every client" B. "A client's rights are guaranteed by both state and federal laws" C. "Being respectful and concerned will ensure that I'm attentive to my client's rights" D. "Regardless of the client's condition, all nurses have the duty to respect client rights"

C. "Being respectful and concerned will ensure that I'm attentive to my client's rights"

The nurse orients a female client with depression to the new room on the mental health unit. The client states "It seems strange that I don't have a T.V in my room." Which statement would be best for the RN to provide? A. "You can watch T.V as much as you want outside of your room." B. "Sometimes clients feel like the T.V is sending them messages." C. "It's important to be out of you room and talking to others." D. "Watching T.V is a passive activity and we want you to be active."

C. "It's important to be out of you room and talking to others."

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? A. "Why did you use the client's name on your clinical worksheet?" B. "You were very careless to refer to your client by name on your clinical worksheet." C. "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name." D. "It is disappointing that after being told, you're still using client names on your worksheet."

C. "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name."

Nurse Patrick is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a general lead? A. "Do you know why you are here?" B. "Are you feeling depressed or anxious?" C. "Yes, I see. Go on." D. "Can you chronologically order the events that led to your admission?"

C. "Yes, I see. Go on."

A patient diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family." C. "You're feeling angry that your family continues to hope for you to be cured?" D. "You are probably very depressed, which is understandable with such a diagnosis."

C. "You're feeling angry that your family continues to hope for you to be cured?"

When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You're having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too."

C. "You're having difficulty sleeping?"

A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to: A. Encourage problem solving B. Encourage accomplishment of the group's work C. Acknowledge the contributions of each group member D. Encourage members to become acquainted with one another

C. Acknowledge the contributions of each group member

The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? A. Don't allow the client to go into the kitchen until the hallucination has subsided. B. Report the behavior to the client's case workers so that the family can be notified. C. Assign the UAP to remain with the client at all times. D. Document the behavior in the client's record and notify the HCP.

C. Assign the UAP to remain with the client at all times.

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes.

C. Assist the client to get out of bed and involved in an activity.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A. Client will not demonstrate cross addiction. B. Co-dependent behaviors will be decreased. C. CNS stimulation will be reduced. D. Client's level of consciousness will increase.

C. CNS stimulation will be reduced.

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A.Perphenazine (Trilafon). B. Diphenylhydramine (Benadryl). C. Chlordiazepoxide (Librium). D. Isocarboxazid (Marplan).

C. Chlordiazepoxide (Librium)

A client is admitted to a medical nursing unit with a diagnosis of acute blindness, many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing: A. Psychosis B. Repression C. Conversion Disorder D. Dissociative Disorder

C. Conversion Disorder

An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but he is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? A. Assess the client's self-esteem needs. B. Determine the client's expectations fortreatment. C. Discuss methods for clearly communicating. D. Identify ways to develop support systems.

C. Discuss methods for clearly communicating.

An older ale client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? A. Explain that the feces belong in the toilet. B. Show the client how to clean the walls. C. Escort the client out of the bathroom. D. Assist the client to clean the walls

C. Escort the client out of the bathroom.

An older male client with schizophrenia is found smearing feces in the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? A. Explain that the feces belong in the toilet. B. Show the client how to clean the walls. C. Escort the client out of the bathroom. D. Assist the client to clean the walls.

C. Escort the client out of the bathroom.

A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly state that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of the situation, the LPN/LVN determines that the appropriate action would be to: A. Orient the client to time, person, and place B. Tell the client that behavior is inappropriate. C. Escort the manic client to her room with assistance D. Tell the client that smoking privileges are revoked for 24 hours

C. Escort the manic client to her room with assistance

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

C. Formulating a plan of action

Which nursing actions are likely to help promote the self-esteem of a male client with moderate depression? (Select all that apply) A. Ask the client what his long-term goals are B. Discuss the challenges of his medical condition C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy E. Provide opportunities for the client to discuss his concerns

C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.

C. Ineffective breathing pattern

C. Ineffective breathing pattern.

Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? A. Medication non-compliance. B. Number of bathroom facilities. C. Infection control. D. Acting out behaviors.

C. Infection control.

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana

C. Methamphetamine

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Useof which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana

C. Methamphetamine

Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time? A. Encourage the client to increase fluid intake. B. Obtain the client's serum Vicodin level. C. Observe the client for further narcotic effects. D. Determine the client's reason for attempting suicide.

C. Observe the client for further narcotic effects.

Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? A. Hamburger, french fries, and chocolate milkshake. B. Liver and onions, broccoli, and decaffeinated coffee. C. Pepperoni and cheese pizza, tossed salad, and soda. D. Roast beef, baked potato with butter, and iced tea.

C. Pepperoni and cheese pizza, tossed salad, and soda.

A client with bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan-seared catfish B. Deep fried shrimp C. Pepperoni pizza D. Beef trips with gravy

C. Pepperoni pizza

A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the RN identify as the priority? A. Give lorazepam (Ativan) PRN for signs of withdrawal. B. Administer disulfiram (Antabuse) immediately. C. Place in a side lying position with head of bed elevated. D. Provide thiamine and folate supplements as prescribed.

C. Place in a side lying position with head of bed elevated.

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? A. Dim the lights in the room to help the patient feel calm. B. Sit within two feet of the client to enhance level of safety and security. C. Reduce the noise level in the room by turning off the television and radio. D. Position table between the client and the RN for extra personal space.

C. Reduce the noise level in the room by turning off the television and radio

C. Reduce the noise level in the room by turning off the television and radio.

A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity. B. Social isolation. C. Refusal to address nutritional needs. D. Low self-esteem.

C. Refusal to address nutritional needs

A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity B. Social isolation C. Refusal to address nutritional needs D. Low self-esteem

C. Refusal to address nutritional needs

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A. Transport the client to the seclusion room B. Quietly approach the client with additional staff members C. Take other client in the area to the client lounge D. Administer medication to chemically restrain client

C. Take other client in the area to the client lounge

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? A. Transport of the client to the seclusion room. B. Quietly approach the client with additional staff members. C. Take other clients in the area to the client lounge. D. Administer medication to chemically restrain the patient.

C. Take other clients in the area to the client lounge.

An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement? A. Tell the client to call Adult Protective Services if his son's abuse continues. B. Refer the client to a program for victims of domestic violence C. Verify the client's report by determining if there is physical evidence of abuse D. Assist the client in developing an emergency safety plan

C. Verify the client's report by determining if there is physical evidence of abuse

A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred? A. Is worried about losing his job to a woman B. Tortured animals as a child C. Was physically abused by his mother D. Hates to be touched by anyone

C. Was physically abused by his mother

A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee's history is most related to the reaction that occurred? A. Is worried about losing his job to a woman. B. Tortured animals as a child. C. Was physically abused by his mother. D. Hates to be touched by anyone.

C. Was physically abused by his mother.

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take? A. instruct the client to reduce the volume of his voice B. administer a PRN sedative by injection C. accompany the client to a quiet area of the unit D. encourage the client to attend a support group

C. accompany the client to a quiet area of the unit

On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the nurse is the most therapeutic? A) "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care." B) "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment." C) "I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential." D) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."

D) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."

A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression? A) Grandiose ideation. B) Self-destructive thoughts. C) Suspiciousness of others. D) A negative view of self and the future.

D) A negative view of self and the future.

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? A) Plan an outing within the first week of admission. B) Distract her whenever she expresses her discomfort about being with others. C) Confront her fears and discuss the possible causes of these fears. D) Accompany her outside for an increasing amount of time each day.

D) Accompany her outside for an increasing amount of time each day.

A newly admitted client describes her mission in life as one of saving her son by eliminating the "provocative sluts" of the world. There are several attractive young women on the unit. What should the nurse do first? A) Ask the client for her definition of "provocative sluts" B) Ask the young female clients on the unit to dress less provocatively C) Ask the client to discuss her concerns in the next group session D) Ask the client to inform the staff if she has negative thoughts about other clients

D) Ask the client to inform the staff if she has negative thoughts about other clients

A client with a leg amputation is upset about his appearance. The nurse intends to address which most closely associated psychosocial problem? A) Inability to be mobile B) Isolating self from others C) Inability to tolerate activity D) Concern about body persona

D) Concern about body persona

A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope? A) Keep the client in her room as much as possible B) Assist the client with all activities of daily living C) Tell the client that many of the people in the facility have these same sorts of problems D) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily

D) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily

The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? A) Your healthcare provider has prescribed ambulation on the first postoperative day. B) You must ambulate to avoid complications which could cause more discomfort than ambulating. C) I know how you feel. You're angry about having to ambulate, but this will help you get well. D) I'll be back in 30 minutes to help you get out of bed and walk around the room.

D) I'll be back in 30 minutes to help you get out of bed and walk around the room.

A nurse is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to: A) Demonstrate confidence in the client's ability to deal with stressors B) Provide hope and reassurance that the problems will resolve themselves C) Display an attitude of detachment, confrontation, and efficiency D) Provide authority, action, and participation

D) Provide authority, action, and participation

The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? A) The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. B) The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. C) The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. D) The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

D) The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A. "If your partner is abusing you, I need to ask these questions." B. "State law mandates that I ask if you are a victim of domestic violence" C. "The HCP provider needs to know if you are experiencing any domestic abuse" D. "All clients are screened for domestic abuse because it is common in our society"

D. "All clients are screened for domestic abuse because it is common in our society"

A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? A. "Unless your sister has a medical education, ignore her comments." B. "I can hear that your sister's comments are overwhelming you." C. "Do you think it's possible that you might be a hypochondriac?" D. "Besides your sister's comments, what in life is troubling you?"

D. "Besides your sister's comments, what in life is troubling you?"

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? A. "What should I do? Nothing seems to help." B. "I have been so tired lately and needed to sleep." C. "I really think that I don't need to be here." D. "I don't want to walk. Nothing matters anymore."

D. "I don't want to walk. Nothing matters anymore."

During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers, how should the nurse respond? A. "Anger is contagious and could result in major confrontation" B. "Try not to let your anger cause you to act impulsively" C. "Expressing your anger to a stranger could result in an unsafe situation" D. "It sounds as if there are many situations that make you feel angry"

D. "It sounds as if there are many situations that make you feel angry"

During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. How should the RN respond? A. "Anger is contagious and could result in major confrontation." B. "Try not to let your anger cause you to act impulsively." C. "Expressing your anger to a stranger could result in an unsafe situation." D. "It sounds as if there are many situations that make you feel angry."

D. "It sounds as if there are many situations that make you feel angry."

A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"

D. "You've been feeling like a failure for a while?"

On review of the patient's record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient's behavior? A. Fearfulness regarding treatment measures. B. Anger and aggressiveness directed toward others. C. An understanding of the pathology and symptoms of the diagnosis. D. A willingness to participate in the planning of the care and treatment plan.

D. A willingness to participate in the planning of the care and treatment plan.

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take? A. Medicate the client with the prescribed antipsychotic thiordazine (mellaril) B. Offer the client a prescribed physical therapy hot pack for muscle spasms C. Direct client to occupational therapy to distract him for somatic complaints D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the RN take? A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril). B. Offer the client a prescribed physical therapy hot pack for muscle spasms. C. Direct client to occupational therapy to distract him from somatic complaints. D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

The Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client's recovery? A. Support group meetings. B. Vitamin B and multivitamin supplements. C. Diet with adequate calories and protein. D. Alcohol abstinence.

D. Alcohol abstinence.

When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A. If your partner is abusing you, I need to ask these questions. B. State law mandates that I ask if you are a victim of domestic violence. C. The HCP provider needs to know if you are experiencing any domestic abuse. D. All clients are screened for domestic abuse because it is common in our society.

D. All clients are screened for domestic abuse because it is common in our society.

A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client's behavior? A. Ineffective protection to guard self from internal or external threats. B. Risk for injury related to inability to communicate. C. Risk prone health behavior related to self-esteem assault. D. Anxiety related to real or perceived threat to physical integrity.

D. Anxiety related to real or perceived threat to physical integrity.

A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? A. Unless your sister has a medical education, ignore her comments. B. I can hear that your sister comments are over-whelming you. C. Do you think it's possible that you might be a hypochondriac? D. Besides your sister's comments, what in your life is troubling you?

D. Besides your sister's comments, what in your life is troubling you?

The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle accident and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis? A. "Tell me what you think should happen." B. "How serious was the collision?" C. "What do you think you should do?" D. Call for transportation to the hospital

D. Call for transportation to the hospital

The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis? A. Tell me what you think should happen. B. How serious was the collision? C. What do you think you should do? D. Call for transportation to the hospital.

D. Call for transportation to the hospital.

On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client's plan of care? A. Lead the client by his arm to the seclusion room. B. Ensure the client's environment is safe. C. Schedule activity therapy twice a week. D. Confront his delusion as not consistent with reality.

D. Confront his delusion as not consistent with reality.

A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? A. Visual hallucinations. B. Auditory hallucinations. C. Excessive motor activity. D. Delusions of persecution.

D. Delusions of persecution.

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first? A. Refer the client to the cardiology unit. B. Obtain the client Blood pressure. C. Assess the client for substance abuse. D. Determine if Xanax was taken recently.

D. Determine if Xanax was taken recently.

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? A. Have you lost interest in the things that you used to enjoy? B. Is your ability to think or concentrate decreased? C. How many continuous hours do you sleep at night? D. Do you hear sounds or voices that others do not hear?

D. Do you hear sounds or voices that others do not hear?

A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? A. Explain to the client that her behavior invades the rights of the nursing staff. B. Ask the client to explain why she is keeping a detailed record of her nursing care. C. Teach the client strategies to control her obsessive compulsive behavior. D. Encourage the client to express her feelings regarding the upcoming procedure.

D. Encourage the client to express her feelings regarding the upcoming procedure.

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from other clients B. Administer PRN sedative C. Avoid recognizing the behavior D. Escort the client to his room

D. Escort the client to his room

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from the other clients. B. Administer PRN sedative. C. Avoid recognizing the behavior. D. Escort the client to his room.

D. Escort the client to his room.

The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members. B. Clarifying the nurse's role and clients' responsibilities. C. Discussing ways to use new coping skills learned. D. Helping clients identify areas of problem in their lives.

D. Helping clients identify areas of problem in their lives.

A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? A. Exploring the client's ability to function B. Exploring the client's potential for self-harm C. Inquiring about the client's perception of appraisal of the neighbor's death D. Inquiring about and examine the client's feelings that may block adaptive coping

D. Inquiring about and examine the client's feelings that may block adaptive coping

A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer? A. Haloperidol (Haldol). B. Thiamine (Vitamin B1). C. Diphenhydramine (Benadryl). D. Lorazepam (Ativan).

D. Lorazapam (Ativan)

Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? A. Prochlorperazine (Compazine) 5 mg IM. B. Hydromorphone (Dialuadid) 2 mg IM. C. Chlorpromazine (Thorazine) 50 mg IM. D. Lorazepam (Ativan) 2 mg IM.

D. Lorazepam (Ativan) 2 mg IM.

Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins toexhibit signs and symptoms of delirium tremens (DTs)? A. Prochlorperazine (Compazine) 5 mg IM. B. Hydromorphone (Dialuadid) 2 mg IM. C. Chlorpromazine (Thorazine) 50 mg IM. D. Lorazepam (Ativan) 2 mg IM.

D. Lorazepam (Ativan) 2 mg IM.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife, or I take it out of the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

D. Making observations

While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take? A. Report family conversations and anger towards the client when visiting. B. Ask the client specific questions about someone causing the bruising. C. Question the family members and caregiver how the bruising occurred. D. Measure and document size, shape and color of the bruised areas.

D. Measure and document size, shape and color of the bruised areas.

The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain? A. Motivation of treatment. B. History of substance use. C. Medication compliance. D. Mental status examination.

D. Mental status examination.

The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting.

D. Nausea and vomiting

The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting.

D. Nausea and vomiting.

A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? A. Assure the client that all food served in the hospital is safe to eat. B. Tell the client that irrational thinking is a symptom of schizophrenia. C. Obtain an order for a tube feeding for the client. D. Provide the client with food in unopened containers.

D. Provide the client with food in unopened containers

The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? A. Explore the client's feelings about his pets and home life. B. Encourage his peers to help involve him in the activity. C. Give the client permission to leave and return in 10 minutes. D. Redirect him by encouraging him to read from the handout.

D. Redirect him by encouraging him to read from the handout.

Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? A. Working B. Trusting C. Orientation D. Termination

D. Termination

A patient's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-patient relationship? A. Trusting B. Working C. Orientation D. Termination

D. Termination rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The client's comfort level is increased when the RN breaks eye contact to take notes. B. The interview process is enhanced with note taking and allows the client to speak at a normal pace. C. Taking notes during an interview is a legal obligation of examining RN. D. The RN's ability to directly observe the client's non-verbal communication is limited with note taking.

D. The RN's ability to directly observe the client's non-verbal communication is limited with note taking.

A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? A. The therapeutic technique of "giving advice" B. The therapeutic technique of "defending" C. The nontherapeutic technique of "presenting reality" D. The nontherapeutic technique of "giving false reassurance"

D. The nontherapeutic technique of "giving false reassurance"

What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks? A. ventilate feelings of sadness B. eats three meals a day C. participates in group meetings D. does not attempt to commit suicide

D. does not attempt to commit suicide

A female client with obsessive compulsive disorder complains that she is feels "driven" to check the locks on her front door at.. Which response is best for the nurse toprovide? A. have you had a bad experience related to unlocked doors? B. What are your thoughts when you are checking the locks? C. feelings of being drive to do something are related to anxiety D. repeating the same behavior helps you to diminish your anxiety

D. repeating the same behavior helps you to diminish your anxiety

woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do?

Walk her to room and help her pick out something more appropriate

Patient says "I'm going to shoot myself"

a. Stop the client from leaving the unit

The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia).

b. Benzotropine (Cogentin).

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? a.) "I am not the best nurse. All the nurses are good." b.) "The other nurses and I are here to help you get better" c.) "You don't think the other nurses care about you?" d.) "I do care about you as a person but nothing more."

b.) "The other nurses and I are here to help you get better"

While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique? a. Initiate a non-threatening conversation with the client. b. Dialogue about the ineffectiveness of his interactions c. Allow the client to identify the way he interacts. d. Discuss the client's feelings when he responds.

c. Allow the client to identify the way he interacts.

A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client's chief complaint in the medical record? a.) Client reported that she had sexual relations against her will. b.) Client claims that she was forced to participate in sexual intercourse. c.) Client has been sexually assaulted. d.) Client states, "my date raped me tonight."

d.) Client states, "my date raped me tonight."

29. client sitting in corner of day room during admission assessment, what nursing action-

ask client simple questions

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