Mental Health Online Practice 2019 B with NGN

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A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team? A) Calling family members B) Spending time alone C) Giving away possessions D) Excessive crying

C Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A) Repeatedly talks about the traumatic incident B) Sleeps excessively C) Experiences feelings of isolation D) Uses repetitive speech

C The nurse should expect clients who have PTSD to feel estranged and detached from others.

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? A) Weight gain B) Tinnitus C) Tachycardia D) Increased salivation

C The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? A) "She works so hard at ballet. Will she still be able to perform?" B) "She won't let me take the trash from her room. I'm concerned about what she has in there." C) "She told me she was tired, so I did her chores for her today." D) "She is happier with her appearance now that she's lost some weight."

B The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's statement indicates awareness of the client's behavior.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A) Orient the client to person, place, and time. B) Assist the client with deep-breathing exercises. C) Calm the client by using therapeutic touch. D) Have the client sit alone in a quiet room.

B Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A) Tell the client to talk less or risk being removed from the meeting. B) Ask group members to discuss their feelings about this client's monopolizing behavior. C) End the group meeting and take the client aside to discuss the disruptive behavior. D) Focus on other group members and ignore the client who is doing all the talking.

B This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A) Provide teaching about the use of positive coping mechanisms. B) Establish screening programs to identify at-risk clients. C) Refer survivors of intimate partner abuse to a legal advocacy program. D) Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

B This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessary steps to address individual client needs.

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A) Call the provider to obtain an immediate prescription for restraint. B) Prepare to administer benzodiazepine IM. C) Call for a team of staff members to help with the situation. D) Check the client who has was hit for injuries.

C The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? A) An adolescent family member who questions parental authority B) A family with three generations in the same household C) Older children who are responsible for their younger siblings D) Two adults and their children from prior relationships in the same household

C This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members.

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A) "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B) "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C) "You don't want to look at yourself because you think you are fat." D) "You and I can work together to overcome your fears of gaining weight."

B The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? A) Rapid improvement in affect within 30 to 60 min after taking the medication B) Greater risk of attempting suicide as affect and energy improve C) Onset of frequent, loose stools D) Development of physiologic dependence on the medication

B The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a plan is increased after 1 week of treatment.

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? A) "It appears as though you would like to open the door." B) "You will feel more comfortable after you've been here for a while." C) "It is okay to not want to be here." D) "You really shouldn't be pushing on the door."

A This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that they can describe thoughts and feelings related to that behavior.

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make? A) "Why do you think you deserve this punishment?" B) "Don't worry about being punished by God." C) "Let's talk about what is upsetting you." D) "You shouldn't say things that will upset you so much."

C The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? A) Document the client's behavior every 8 hr. B) Limit the client's fluid intake to 50 mL/hr. C) Renew the prescription for the client every 4 hr. D) Toilet the client every 4 hr.

C The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? A) "I will avoid social events until my partner has completed treatment." B) "It is important for me to focus my attention on my partner's addiction." C) "I will not take charge of my partner's work responsibilities." D) "I want my partner to promise to change addictive behaviors."

C The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? A) Increased creatine phosphokinase (CPK) B) Increased low-density lipoproteins (LDL) C) Decreased fasting blood glucose D) Decreased aspartate aminotransferase (AST)

A An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.) A) Occupational therapy B) Meal delivery services C) Speech-language pathologist D) Physical therapy E) Home health services

A, B, D, and E Occupational therapy is correct. An occupational therapist can assist the client to perform ADLs. Meal delivery services is correct. Meal delivery services are necessary due to the client's difficulty performing ADLs. Physical therapy is correct. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services is correct. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Diagnostic Results Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) A nurse is assessing a client who is displaying manifestations of delirium. Which of the following information from the client's medical record are risk factors for delirium? (Select all that apply.) A) Fever B) Omeprazole use C) Hospital environment D) Enoxaparin use E) Client's age F) Family at bedside G) Postoperative

A, C, E, and G Hospital environment is correct. Risk factors for delirium include a change in hospital rooms, such as moving from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. A change in room location can be disorienting to a client and lead to delirium. Client's age is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision and hearing impairments, recent surgical procedures, and infection. Older adult clients have a higher risk for developing delirium from being in unfamiliar surroundings, such as a hospital. Postoperative is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. Surgical procedures increase a client's risk for delirium due to the effects of anesthesia and pain medications, the risk for infection, and the potential for altered vital signs and fluid and electrolyte balance. Fever is correct. Risk factors for delirium include a change in hospital rooms, such as from the ICU to a private room, client's age, vision or hearing impairments, recent surgical procedures, and infection. Altered vital signs and the risk for infection, as evidenced by fever, increase a client's risk for developing delirium.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A) A school-age child who has bruises on the knees B) An older adult client who is bedbound and has a stage IV pressure ulcer C) An adolescent who has a vaginal candida infection D) A young adult who is pregnant and has a sprained ankle

B A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? A) Amenorrhea B) Lanugo C) Cold extremities D) Tooth erosion

D A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

A nurse is caring for a client who has a personality disorder. Nurses' Notes Day 1 - Admit note 0700 Talkative, well-groomed.States she is "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Day 2 1000 Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Diagnostic Results Day 1 0730 Hematocrit 45% (female: 37% to 47%) Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) Graphic Record Day 1 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 0900 Temperate 36.7° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Provider Prescriptions Admit orders Day 1 Regular diet Activity as tolerated Observe closely for self-injury or violence toward others Buspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Complete the following sentence by using the lists of options. The client is at risk for developing ___1___ as evidenced by the client's ___2___. Options for 1 A) Violent behavior B) Anorexia C) Hypertension D) Anemia Options for 2 A) Hematocrit level B) Increased agitation C) Heart rate D) Regular exercise

1) A 2) B

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? A) Complete documentation about the client's status every hour while they are in restraints. B) Maintain the client in restraints for a minimum of 4 hr. C) Apply restraints when other means of managing the client's behavior have failed. D) Request that the provider assess the client within 8 hr of the application of restraints.

C According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? A) "I am going to order a wheelchair for when I'm unable to walk." B) "I am going to stop paying my bills since I won't be around much longer." C) "I wish you would go take care of somebody who actually needs you." D) "I am sure I'm going to be able to continue to care for myself without help."

A The client is recognizing the reality of continued loss of independence and is anticipating the need for assistive devices, which indicates the behavioral response of acceptance.

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make? A) "Clients can't refuse to take medications if they are admitted involuntarily." B) "You can notify a client's family if they are admitted involuntarily." C) "Clients who are admitted involuntarily maintain the right to give informed consent for procedures." D) "You can remove a client's privileges if they are admitted involuntarily and refuse to attend therapy sessions."

C Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for procedures.

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? A) The client is married. B) The client recently received a promotion at work. C) The client has COPD. D) The client is a male.

C The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

Nurse's Notes The client reports a history of anxiety; diagnosed with Alzheimer's disease 2 months ago. The client's partner died 6 months ago. Reports decreased appetite, low energy levels, and insomnia for several weeks; some memory loss. Graphic Results SaO2 96% on room air Respiratory rate 20/min Blood pressure 112/76 mm Hg (lying) Blood pressure 104/68 mm Hg (standing) Heart rate 68/min Temperature 36° C (96.8° F) Medication Administration Record Captopril 12.5 mg by mouth three times daily Digoxin 0.125 mg by mouth each morning Multivitamin with iron one by mouth daily Docusate sodium 50 mg by mouth each evening A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? A) Use a screening tool to evaluate the client for depression. B) Ask the provider to decrease the dosage of the client's blood pressure medication. C) Instruct the client to decrease intake of vitamin B12. D) Suggest the client go for a brisk walk 20 min just before bedtime.

A Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety, and the loss of a loved one. Manifestations of depression can also be nonspecific for older adult clients and can include weight loss, decreased energy levels, and difficulty sleeping.

A nurse is evaluating the client after 2 weeks. Which of the following findings indicate an improvement in the client's condition? (Select all that apply.) A nurse is caring for a client who has anorexia nervosa. Vital Signs Day 1: Blood pressure 90/60 mm Hg Heart rate 54/min Respiratory rate 16/min Temperature 36.1° C (97° F) Day 14: Blood pressure 88/58 mm Hg Heart rate 64/min Respiratory rate 16/min Temperature 36.1° C (97° F) Diagnostic Results Day 1: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Sodium 150 mEq/L (136 to 145 mEq/L) BUN 35 mg/dL (10 to 20 mg/dL) Glucose 78 mg/dL (74 to 106 mg/dL) Day 14: Potassium 3.7 mEq/L (3.5 to 5.0 mEq/L) Sodium 143 mEq/L (136 to 145 mEq/L) BUN 18 mg/dL (10 to 20 mg/dL) Glucose 76 mg/dL (74 to 106 mg/dL) Physical Examination Day 1: • BMI 16.8 • Yellow sclera • Skin is cool • Reports no bowel movement for 5 days • 1+ peripheral edema • Reports exercising 2 hr per day Day 14: • BMI 17.8 • Yellow sclera • Skin is warm • Reports last bowel movement 1 day ago • 1+ peripheral edema • Reports exercising 2 hr per day A) Blood pressure B) Sodium C) Heart rate D) Bowel movement E) Skin temperature F) Peripheral edema G) Glucose H) BUN I) Potassium J) BMI

B, C, D, E, H, I, and J Heart rate is correct. Clients who have anorexia nervosa usually have bradycardia. The client's heart rate is now within the expected reference range. BMI is correct. Clients who have anorexia nervosa usually have a BMI of less than 17. The client's initial BMI indicates moderate anorexia nervosa while the current BMI indicates mild anorexia nervosa. Potassium is correct. Clients who have anorexia nervosa usually have hypokalemia. The client's potassium level is now within the expected reference range. Skin temperature is correct. Clients who have anorexia nervosa usually have cool skin. After 2 weeks, the client's skin is warm, which indicates improvement. Sodium is correct. Clients who have anorexia nervosa usually have hyponatremia. The client's sodium level is now within the expected reference range. Bowel movement is correct. The client's constipation has improved based on the increased frequency of their bowel movements. BUN is correct. Clients who have anorexia nervosa usually have an increased BUN. The client's BUN level is now within the expected reference range.

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take? A) Assist the client to identify personal areas of strength. B) Encourage the client to talk about experiences during the deployment. C) Stay with the client when flashbacks occur. D) Teach the client stress-management techniques.

C The greatest risk to this client is injury that can occur during a flashback; therefore, the priority intervention for the nurse is to remain with the client and offer reassurance and support when flashbacks occur.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A) Encourage the client to participate in group therapy. B) Instruct the client to avoid napping during the day. C) Offer the client high-calorie finger foods frequently. D) Decrease the client's daily fiber intake.

C The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "I will use the same plan of care and interventions for each client who has depression." B) "Each nurse will develop a separate plan of care for each client who has depression." C) "I will update the plan of care as a client's manifestations of depression change." D) "An assistive personnel can use the plan of care for client teaching."

C The nurse should update the plan of care as a client's status and needs change.

C, D, E, F, I, and J Stealing money from family to cover credit card charges is correct. The nurse should identify that stealing money is an impulsive behavior, which is a manifestation of borderline personality disorder. Anxious if left alone is correct. The nurse should identify that the client's anxiety about being left alone is due to fear of separation, which is a manifestation of borderline personality disorder. Hypersexualization is correct. The nurse should identify that hypersexualization is an impulsive, self-damaging behavior, which is a manifestation of borderline personality disorder. Married multiple times is correct. The nurse should identify that unstable romantic relationships are a manifestation of borderline personality disorder. Incidences of self-injury is correct. The nurse should identify that self-injury is a manifestation of borderline personality disorder. Self-destructive behaviors, such as cutting, are common with this disorder. Physical altercations is correct. The nurse should identify that engaging in physical altercations is a manifestation of borderline personality disorder.

A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event. Vital Signs 0730: Temperature 36.6° C (97.8° F) Heart rate 74/min Respiratory rate 16/min Blood pressure 118/74 mm Hg 1400: Temperature 36.9° C (98.4° F) Heart rate 86/min Respiratory rate 18/min Blood pressure 114/78 mm Hg Nurses' Notes 0730 Admission: Client was a witness during a recent violent crime at their place of employment. Several of the client's coworkers were killed. The client has been experiencing feelings of guilt and anger. 1400: The client continues to express feelings of guilt and anger and states, "I cannot ever go back to work. It is too dangerous." The client also states, "I don't know why I was allowed to survive. It's too painful to talk to my friends and family about what happened." The nurse is providing teaching to the client. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A) "It is uncommon for people who survived a traumatic event to experience spiritual distress." B) "You will have minimal problems performing your daily self-care tasks." C) "You should seek help if you have thoughts of self-harm." D) "A support group might be helpful to you during this time." E) "It is common for people who survived a traumatic event to experience feelings of anxiety."

C, D, and E "You should seek help if you have thoughts of self-harm" is correct. The nurse should inform the client that they should seek help immediately if they experience thoughts of self-harm or suicidal ideation. "A support group might be helpful to you during this time" is correct. The nurse should encourage the client to participate in a support group, which can provide emotional support for a client who has experienced a traumatic event. "It is common for people who survived a traumatic event to experience feelings of anxiety" is correct. Clients who have experienced a traumatic event can demonstrate manifestations of severe anxiety and panic attacks, including impulsivity and regression.

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? A) Allowing a client to choose which unit activities to attend B) Attempting alternative therapies instead of restraints for a client who is combative C) Providing a client with accurate information about their prognosis D) Spending adequate time with a client who is verbally abusive

D By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first? A) A client who has avoidant personality disorder and refuses to attend group therapy B) A client who has bipolar disorder and reports being kidnapped by aliens overnight C) A client who is taking bupropion and reports having insomnia the past 2 nights D) A client who is taking clozapine and reports a sore throat and chills

D When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that causes neutropenia. The nurse should withhold the medication and notify the provider of these findings.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance.Placed call to provider to report findings. Awaiting call-back. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Diagnostic Results Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. 1) Melatonin 2) Apply restraints 3) Urinalysis with culture and sensitivity 4) MRI of the head 5) Insert indwelling urinary catheter 6) IV fluids A) Anticipated B) Nonessential C) Contraindicated

1) A 2) C 3) A 4) B 5) C 6) A

A nurse is caring for a client who is experiencing delirium. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism. No known allergies. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 0900: Return call from client's provider, update given, prescriptions received. Upon entering client's room, find client attempting to get out of bed. Client's family is trying to stop them. Client is agitated and disoriented to place, attempting to pull out IV device, becomes incontinent of urine in the bed. Client's family states, "That has never happened before." Reassurance offered to client and their family. Assistive personnel called to help with bathing client and changing linens. Client calmer following hygiene and comfort measures. States having knee pain of 5 on a scale of 0 to 10. Requested client's family member to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 0930: Administered hydrocodone for report of knee pain. Client resting quietly at this time. Family members at bedside. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 0900:Daily weight IV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hr Encourage PO fluids Urine for urinalysis and culture and sensitivity Discontinue morphine Melatonin 1 mg PO 2 hr before bedtime Diagnostic Results Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) The nurse is planning care for the client who has delirium and new prescriptions. Complete the following sentence by using the lists of options. The nurse should first ___1___, followed by ___2___. Options for 1 A) Obtain a urine sample B) Administer melatonin C) Initiate IV fluids Options for 2 A) Administering acetaminophen B) Preparing discharge teaching C) Weighing the client

1) C 2) A

A nurse is caring for a client who has a personality disorder. Nurses' Notes Day 1 - Admit note 0700 Talkative, well-groomed.States she is "looking forward to divorcing partner number four" because she has "found my next partner."Anxious if left alone - wants to remain close to nurse.Tells the nurse, "I feel like a bomb waiting to explode." Diagnostic Results Day 1 0730 Hematocrit 45% (female: 37% to 47%) Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) Graphic Record Day 1 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Provider Prescriptions Admit orders Day 1 Regular dietActivity as toleratedObserve closely for self-injury or violence toward othersBuspirone 7.5 mg PO twice a dayHaloperidol 2 mg IM every 3 hr PRN severe agitationBacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 For each potential provider's prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than one disease process. 1) Validation therapy 2) Systematic desensitization 3) Fluoxetine 20 mg PO daily 4) Dialectical behavior therapy 5) Donepezil 5 mg PO daily A) Obsessive Compulsive Disorder B) Dementia C) Borderline Personality Disorder

1) B 2) A 3) A and C 4) C 5) B

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.5

A nurse is reviewing a client's medical record. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not complained of pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 0900: Return call from client's provider, update given, prescriptions received.Upon entering client's room, find client attempting to get out of bed. Client's family is trying to stop them. Client is agitated and disoriented to place, attempting to pull out IV device, becomes incontinent of urine in the bed. Client's family states, "That has never happened before." Reassurance offered to client and their family. Assistive personnel called to help with bathing client and changing linens.Client calmer following hygiene and comfort measures. States having knee pain of 5 on a scale of 0 to 10. Requested client's family member to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 0930: Administered hydrocodone for report of knee pain. Client resting quietly at this time. Family members at bedside. Day 4 0800: Experienced confusion and insomnia through the night. Client oriented to person, place, and time this morning. Appears fatigued. Incisional site clean, dry, and intact. Client ambulating with a walker with physical therapy 3 times daily. Physical therapy staff reports client ambulating half the distance as previously due to weakness and fatigue. Client reports pain as 2 on a scale of 0 to 10. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight: 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Day 4 0800: Heart rate 85/min Respiratory rate 16/min Blood pressure 126/68 mm Hg Temperature 37.2° C (98.9° F) Oxygen saturation 98% on room air Today's weight: 64.5 kg (142 lb) Intake and Output (I&O)I = 1,950 mLO = 2,000 mL Diagnostic Results Day 3 0800: Capillary blood glucose: 92 mg/dL (82 to 115 mg/dL) Day 4 0800: Capillary blood glucose 102 mg/dL (82 to 115 mg/dL) Urinalysis: Urine specific gravity 1.008 (1.005 to 1.030) pH 6.5 (4.6 to 8.0) Protein 10 mg/dL (0 to 8 mg/dL) WBC: many (none)RBC: many (none) History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Has been complaining of increasing pain to the right knee following their daily walk of 3 miles. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism. No known allergies. Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 0900: Daily weight IV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hr Encourage PO fluids Urine for urinalysis and culture and sensitivity Discontinue morphine Melatonin 1 mg PO 2 hr before bedtime The nurse is evaluating the client's response to treatments. For each assessment finding, click to specify if the finding is an improvement, no change, or a decline in the client's condition. 1) Sleep/wake cycle 2) Pain level 3) Glucose level 4) Vital signs 5) Daytime orientation 6) I&O 7) Ambulation A) Improvement B) No Change C) Decline

1) B 2) A 3) B 4) A 5) A 6) A 7) C

A nurse is caring for a client who has a personality disorder. Nurses' notes Day 1 - Admit note 0700 Talkative, well-groomed. States she is "looking forward to divorcing partner number four" because she has "found my next partner." Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2 1000 Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Day 2 1200 Cursing at staff and other clients. Knocked over the card table in the day room. Attempted to hit one of the nursing staff. Haloperidol 2 mg IM administered left ventrogluteal at 1205 for severe agitation and violent outbursts. Placed in seclusion and mechanical four-point restraints, as per facility policy for safety of client and others on unit. Provider informed and prescriptions received as per protocol. Diagnostic Results Day 1 0730 Hematocrit 45% (female: 37% to 47%) Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) Graphic Record Day 1 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 0900 Temperature 36.7° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Provider Prescriptions Admit orders Day 1 Regular diet Activity as tolerated Observe closely for self-injury or violence toward others Buspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation. Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily Day 2 1215 Seclusion and mechanical restraint protocol Medication Administration Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Day 2 Buspirone 7.5 mg PO at 0800 Bacitracin ointment applied to leg and arm Haloperidol 2 mg IM left ventrogluteal at 1205 wounds at 0800 The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined. 1) Client is silent and glaring at staff. 2) Client attempts to bite nursing staff when offered water. 3) Client follows instructions of the nurse. 4) Client verbalizes precipitating factors to violent outburst. A) Improved B) No Change C) Declined

1) B 2) C 3) A 4) A

A nurse is caring for a client who has a personality disorder. Nurses' Notes Day 1 - Admit note 0700 Talkative, well-groomed. States she is "looking forward to divorcing partner number four" because she has "found my next partner." Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2 1000 Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Diagnostic Results Day 1 0730 Hematocrit 45% (female: 37% to 47%) Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) Graphic Record Day 1 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 0900 Temperature: 36.7° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Provider Prescriptions Admit orders Day 1 Regular diet Activity as tolerated Observe closely for self-injury or violence toward others Buspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily Medication Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client. 1) Hold next dose of buspirone. 2) Haloperidol 2 mg IM 3) Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it." 4) Request change of diet to mechanical soft. 5) Request prescription for digoxin 1 mg IV bolus STAT. A) Anticipated B) Nonessential C) Contraindicated

1) C 2) A 3) A 4) B 5) C

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? A) Inform the client that this admission is confidential. B) Introduce the client to other clients in the day room. C) Assist the client in facilitating behavioral change. D) Determine coping strategies that the client has used in the past.

A According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take? A) Move the client who has bipolar disorder to a private room. B) Administer sleep medication to the client who has bipolar disorder. C) Move the client who has severe depression to a private room. D) Administer sleep medication to the client who has severe depression.

A Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefore, the nurse should move this client to a private room.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? A) WBC count 2,500/mm3 B) Hgb 11.5 mg/dL C) Platelets 150,000/mm3 D) RBC count 3.5 million/mm3

A Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the provider.

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? A) Nonmaleficence B) Veracity C) Justice D) Autonomy

A It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include? A) Additional acute episodes of depression are unlikely following inpatient care. B) Early identification of changes, such as decreased social involvement, is important. C) Medication compliance will prevent further need for inpatient hospitalization. D) It is helpful to regularly reinforce to the client that things will get better.

B Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention.

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? A) Include a liquid supplement with meals. B) Identify the client's trigger foods. C) Allow the client at least 1 hr for each meal. D) Weigh the client at bedtime each day.

B The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? A) Sedation B) Rhinorrhea C) Bradycardia D) Hypothermia

B The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? A) The program will help the client accept responsibility for the disorder. B) The client should obtain a sponsor before discharge for an increased chance of recovery. C) The client will need to identify individuals who have contributed to the disorder. D) The program will need a prescription from the client's provider prior to attendance.

B The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponsor, they can be assigned one when they begin attending the program.

A nurse is caring for a client who has a personality disorder. History and Physical 36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. Nurses' Notes Day 1 - Admit note 0700 Talkative, well-groomed. States she is "looking forward to divorcing partner number four" because she has "found my next partner" Anxious if left alone - wants to remain close to nurse. Tells the nurse, "I feel like a bomb waiting to explode." Day 2 1000 Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched. Day 2 1200 Cursing at staff and other clients. Knocked over the card table in the day room. Attempted to hit one of the nursing staff. Haloperidol 2 mg IM administered left ventrogluteal at 1205 for severe agitation and violent outbursts. Placed in seclusion and mechanical four-point restraints, as per facility policy for safety of client and others on unit. Provider informed and prescriptions received as per protocol. Graphic Record Day 1 0715 Temperature 36.2° C (97.2° F) Heart rate 86/min Respiratory rate 16/min Blood pressure 112/76 mm Hg Day 2 0900 Temperature 36.7° C (98.2° F) Heart rate 98/min Respiratory rate 20/min Blood pressure 118/78 mm Hg Provider Prescriptions Admit orders Day 1 Regular diet Activity as tolerated Observe closely for self-injury or violence toward others Buspirone 7.5 mg PO twice a day Haloperidol 2 mg IM every 3 hr PRN severe agitation Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily Day 2 1215 Seclusion and mechanical restraint protocol Diagnostic Results Day 1 0730 Hematocrit 45% (female: 37% to 47%) Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL) Fasting blood glucose 92 mg/dL (74 to 106 mg/dL) Medical Administration Record Day 1 Buspirone 7.5 mg PO at 0800 and 2000 Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000 Day 2 Buspirone 7.5 mg PO at 0800 Bacitracin ointment applied to leg and arm wounds at 0800 Haloperidol 2 mg IM left The nurse is caring for the client. Which of the following actions should the nurse take? (Select all that apply.) A) Document the client's condition every 30 min. B) Maintain the client NPO during time in restraints. C) Maintain continuous observation of the client while in restraints. D) Remove two restraints at a time as the client regains control. E) Ensure the client is in prone position. F) Conduct debriefing with the client and other staff.

B and F Maintain continuous observation of the client while in restraints is correct. The nurse should ensure a staff member remains with the client continuously while the client is in restraints. Conduct debriefing with the client and other staff is correct. The nurse should conduct debriefing with other staff members to indicate the necessity of the intervention and to ensure that quality care was provided. The nurse should conduct a debriefing with the client to discuss their thoughts about what contributed to the intervention and strategies for crisis prevention in the future.

A nurse is caring for a client who is experiencing delirium. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles. History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism. No known allergies. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Day 3 0900: Return call from client's provider, update given, prescriptions received. Upon entering client's room, find client attempting to get out of bed. Client's family is trying to stop them. Client is agitated and disoriented to place, attempting to pull out IV device, becomes incontinent of urine in the bed. Client's family states, "That has never happened before." Reassurance offered to client and their family. Assistive personnel called to help with bathing client and changing linens. Client calmer following hygiene and comfort measures. States having knee pain of 5 on a scale of 0 to 10. Requested client's family member to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Day 3 0930: Administered hydrocodone for report of knee pain. Client resting quietly at this time. Family members at bedside. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Day 3 0900: Daily weight IV bolus of 0.9% sodium chloride 150 mL/hr for first 4 hr, then decrease to 75 mL/hr Encourage PO fluids Urine for urinalysis and culture and sensitivity Discontinue morphine Melatonin 1 mg PO 2 hr before bedtime Diagnostic Results Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) The nurse is caring for the client. Which of the following actions should the nurse take for this client? (Select all that apply.) A) Turn off all the lights in the client's room. B) Approach the client from the front and speak slowly. C) Offer the client warm milk at bedtime. D) Maintain a low-stimulation environment for the client. E) Use detailed information when explaining care to the client.

B, C, and D Offer the client warm milk at bedtime is correct. This will help the client to relax and encourage sleep. Maintain a low-stimulation environment for the client is correct. Overstimulation can worsen the client's manifestations of delirium. Maintaining a quiet environment will help the client to relax and encourage sleep. Approach the client from the front and speak slowly is correct. The nurse should approach the client from the front and speak slowly to avoid startling the client.

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? A) A 17-year-old client who lives with friends B) A 50-year-old client who has a blood alcohol level of 80 mg/dL C) A 35-year-old client who has major depressive disorder D) A 65-year-old client who just received a dose of morphine

C A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? A) Offer the client various choices for meal selection. B) Assign different nursing personnel for each shift. C) Permit the client to perform daily rituals to decrease anxiety. D) Maintain an environment that has low lighting.

C The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium? A) Slow onset B) Aphasia C) Confabulation D) Easily distracted

D Extreme distractibility is a hallmark manifestation of delirium.

A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? A) A client who does not recognize familiar people B) A client who cannot verbalize their needs C) A client who is awake and disoriented at night D) A client who is experiencing delusions of persecution

D The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse should assess this client first.

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A) Administer phenytoin 30 min prior to the procedure. B) Instruct the client to expect a headache following the procedure. C) Place the client in four point restraints prior to the procedure. D) Monitor the client's cardiac rhythm during the procedure.

D The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their child's illness? A) "This disease will increase our child's risk for high blood pressure." B) "It is important for our child to have regular dental checkups." C) "We need to weigh our child daily for several weeks, then once per week." D) "Bleeding during our child's periods will increase because of this disease."

B For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? A) "I will spend extra time at work to keep from feeling depressed." B) "I will talk about my feelings with a close friend." C) "I will be able to learn how to prevent my partner's attacks." D) "I will use meditation instead of taking my antidepressant."

B Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others? A) Inability to communicate with others B) Feelings of absence of self-worth C) Lack of motivation to perform daily tasks D) Command hallucinations

D A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others.

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home? A) Community mental health center B) Mental health day program C) Partial hospitalization program D) Assertive community treatment

D Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups are important for a client who has bulimia nervosa Nurse's Notes The client reports a history of anxiety; diagnosed with Alzheimer's disease 2 months ago. The client's partner died 6 months ago. Reports decreased appetite, low energy levels, and insomnia for several weeks; some memory loss. Graphic Results SaO2 96% on room air Respiratory rate 20/min Blood pressure 112/76 mm Hg (lying) Blood pressure 104/68 mm Hg (standing) Heart rate 68/min Temperature 36° C (96.8° F) Medication Administration Record Captopril 12.5 mg by mouth three times daily Digoxin 0.125 mg by mouth each morning Multivitamin with iron one by mouth daily Docusate sodium 50 mg by mouth each evening A) Use a screening tool to evaluate the client for depression. B) Ask the provider to decrease the dosage of the client's blood pressure medication. C) Instruct the client to decrease intake of vitamin B12. D) Suggest the client go for a brisk walk 20 min just before bedtime.

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? A) Fear of abandonment B) Motor and verbal tics C) Hostile behavior D) Language delay

D The nurse should identify that language delays are a manifestation of autism spectrum disorder.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? A) Panic B) Moderate C) Severe D) Mild

D The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider? A) Obsessive attention to detail B) Inability to sleep C) Reports of fatigue D) Isolation from others

B During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? A) Response prevention B) Guided imagery C) Aversion therapy D) Light therapy

B Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? A) Develop a code word that means "time to go." B) Identify signs of escalation of violence. C) Have a predetermined place to go in the event of violence. D) Keep a hidden packed bag of necessities.

B It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases awareness of when danger is imminent and it is time to leave.

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? A) Encourage the parents to avoid discussing the death with their other children to protect their feelings. B) Recommend each parent grieve in private to avoid hindering each other's healing. C) Suggest forming a weekly support group for parents who have experienced the death of a child. D) Advise the parents to begin counseling if they are still grieving in a few months.

C Support groups are a positive resource in the process of recovery for parents following the death of a child.

A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty. History and Physical Day 1 0800: 75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies. Nurses' Notes Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours. Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain. Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance. Placed call to provider to report findings. Awaiting call-back. Graphic Record Day 3 0800: Heart rate 115/min Respiratory rate 20/min Blood pressure 90/48 mm Hg Temperature 38.6° C (101.5° F) Oxygen saturation 96% on room air Weight 63.5 kg (140 lb) Intake and Output (I&O)I = 750 mLO = 2,500 mL Provider Prescriptions Day 1: Enoxaparin 30 mg subcutaneously twice daily Levothyroxine 75 mcg PO once daily Omeprazole 20 mg PO once daily Pravastatin 40 mg PO once daily at bedtime Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain Hydrocodone 5 mg PO every 6 hr PRN pain Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F) Diagnostic Results Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL) Which of the following findings should the nurse report to the provider immediately? Select the 5 findings that require immediate follow-up. A) Surgical site B) Oxygen saturation C) Blood pressure D) Blood glucose level E) I&O F) Cognitive awareness G) Temperature H) Sleep/wake cycle

C, E, F, H, and G Cognitive awareness is correct. The nurse should evaluate the client for previous and current cognitive status to provide a safe environment. The client's sudden change in cognitive awareness should be reported to the provider because delirium is a medical emergency. Blood pressure is correct. The client's blood pressure is above the expected reference range and should be reported to the provider. Clients who are experiencing delirium might experience an elevated heart rate and blood pressure. Sleep/wake cycle is correct. The client's lack of sleep and restlessness during the night are indications that the client might be experiencing delirium and should be reported to the provider. Confusion and disorientation are often worse at night. I&O is correct. The client's intake of 750 mL is significantly less than the output of 2,500 mL and should be reported to the provider. The imbalance in fluid status, and the resulting alteration in heart rate and blood pressure, could be a cause of the client's delirium. Temperature is correct. A temperature of 38.6° C (101.5° F) on day 3 following right knee arthroplasty is above the expected reference range and should be reported to the provider.

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A) Lansoprazole B) Naproxen C) Magnesium hydroxide D) Phenylephrine

D Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension.

A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A) Discuss outpatient resources with a client who has post-traumatic stress disorder. B) Create a plan of care for a client who is experiencing alcohol withdrawal. C) Explain sleep hygiene to a client who has insomnia. D) Stay with a client who has anorexia nervosa for 1 hr after mealtimes.

D Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and this task does not require assessment or technical skill.

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)? A) Clinging behaviors directed toward a teacher B) Increased time spent sleeping C) Intense focus on school work D) Lack of interest in an upcoming holiday

D The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events such as holidays.

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? A) Encourage expression of feelings. B) Support the child's attendance at an assertiveness training group. C) Assist the child to perform relaxation breathing. D) Reduce environmental stimuli.

D The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects? A) Blurred vision B) Orthostatic hypotension C) Dry mouth D) Acute dystonia

D The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A) Somnolence B) Blood pressure 154/96 mm Hg C) Pinpoint pupils D) Blood glucose 210 mg/dL

B Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever.

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? A) "You probably want to hold your baby." B) "I'll stay with you just in case you want to talk." C) "I know how you must be feeling." D) "It hurts now, but things will be better soon."

B This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.

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