N481 HESI Practice

which action would the school nurse take for a child who tells the nurse, "My father has been getting into bed with me at night and touching me"?

report the child's conversation to child protective services

which client statement indicates that the client is experiencing a maturational crisis? moved out of parents house divorce problem with nursing professor vague feelings of uneasiness

"I just moved out of my parent's house; I should be happy, but I feel overwhelmed"

which priority concern would the nurse monitor for while working with clients withdrawing from cocaine?

risk for self-injury

symptoms of neuroleptic malignant syndrome

-hyperthermia (fever), muscle rigidity, autonomic instability and mental status changes, sweating, tachycardia -elevated CK, leukocytosis -metabolic acidosis

which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is the president?

schizotypal magical thinking, odd beliefs, strange speech patterns, and inappropriate affect

which type of group is Alcoholics Anonymous?

self-help group

A client reports to the nurse, "I'm afraid of every little thing and I have a fear of dying. My heart races all the time, and I break out in sweats." Which first-line medications would the nurse anticipate developing a teaching plan for? sertraline fluoxetine phenelzine alprazolam imipramine

sertraline, fluoxetine

which intervention will the nurse use for a client diagnosed with borderline personality disorder to develop healthier coping mechanisms?

set realistic limits on maladaptive behavior

which action would be difficult for a client who has borderline personality disorder to complete during the orientation phase of a therapeutic relationship?

setting mutual goals for the relationship

which conclusion would the nurse make about a depressed, suicidal client who greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long"?

increased risk of suicide

which biophysical need is the priority in the acute phase of bipolar disorder, manic episode?

physical

Which activity would be appropriate for the nurse to introduce to a depressed client during the early part of hospitalization? board game project involving drawing intense aerobic exercise group card game with three other clients

project involving drawing

which nursing intervention would be most important for a client who has a diagnosis of antisocial personality disorder?

providing clear boundaries and consequences

which clinical manifestation is associated with depression? flight of ideas suspicion of others psychomotor retardation intrusive social behavior

psychomotor retardation

which action by the nurse would decrease the risk of injury for a child with oppositional defiant disorder?

redirect anger in other ways

which disorder would the nurse classify as neurodevelopmental? anxiety bipolar disorder schizophreniform disorder ADHD

ADHD

the nurse is caring for a client take an SSRI for depression. which statement by the client requires additional teaching? "I should take the medication at the same time daily" "I can stop taking this medication when I feel better" "I will exercise to control any weight gain the medication might cause" "I need to report any agitation I experience to the health care provider"

I can stop taking this medication when I feel better

an older adult client reports flashbacks related to his experiences in Vietnam; he exhibits startle reactions and poor concentration. which mental disorder is associated with these symptoms?

PTSD

which behavior indicated codependence for the spouse of a partner who abuses multiple drugs?

attempts to cover up the partners drug use

which type of hallucinations is the most common?

auditory

which behavior is most commonly used by an individual with a phobic disorder?

avoidance

which statement is accurate for adolescent suicide behavior? boys account for more attempts compared to girls girls use more dramatic methods compared to boys girls talk more about suicide before attempting boys are more likely to use lethal methods than are girls

boys are more likely to use lethal methods than are girls

which clinical finding is a positive sign or symptom for a client with the diagnosis of schizophrenia? anergy flat affect social withdrawal disorganized thoughts auditory hallucination

disorganized thoughts, auditory hallucinations

the client reports screaming hysterically whenever a spider comes close to her. which defense mechanism is the client using?

displacement

which action would the nurse take when working with a client who is depressed? accept what the client says attempt to keep the client occupied keep the client's surroundings cheery try to prevent the client from talking too much

accept what the client says

which action would be required of the client with an alcohol use disorder who attends alcohol anonymous meetings?

acknowledging an inability to control the alcoholism

the nurse is teaching the parent of a 6 year old child with ADHD about the administration of methylphenidate. which statement by the parent indicates an understanding of when they should administer the medication?

after breakfast

which point in the daily routine correctly describes when clients who experience alterations in perception tend to have more problems with vivid hallucinations?

after going to bed

which information would support the nurse's decision to arrange for a staff member to remain with a depressed client continuously? refusal to eat any food inability to concentrate agitated pacing in the hall history of suicide attempts statements that life is not worth living

agitated pacing in the hall, history of suicide attempts, statements that life is not worth living

which clinical manifestation would the nurse assess for in a client a few hours into alcohol withdrawal? agitation tremulousness yawning convulsions profuse diaphoresis

agitation, tremulousness

Which substance is the CAGE questionnaire used to screen?

alcohol

Which substance listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is considered addictive and therefore, a substance of possible abuse? alcohol caffeine cannabis hallucinogens gambling antianxiety medications

alcohol, caffeine, cannabis, hallucinogens, antianxiety medications

which primary anxiolytic medication would the nurse anticipate developing a teaching plan for when a client with social anxiety disorder has a history of exhibiting an intense, irrational fear of being scrutinized by others? sertraline paroxetine alprazolam venlafaxine clonazepam

alprazolam, clonazepam

which symptoms are classified as negative symptoms for a client diagnosed with schizophrenia?

anergy, anhedonia

which term describes a client who states that she no longer enjoys any of the activities that she once found fun and pleasurable?

anhedonia

which reaction is most likely to occur when the performance of a ritual is interrupted for a client with OCD?

anxiety

which behavior is characteristic of oppositional defiant disorder?

argues with adults

which time indicates when the nurse would be alert to the possibility of a depressed client acting out suicidal thoughts?

as the depression lifts

which approach would the nurse use for a delusional client who refuses to eat because of a belief that the food is poisoned?

refusing to argue about the food being poisoned

which behavior is characteristic of panic during a crisis? being physically immobile sobbing for no apparent reason difficulties with falling asleep startling to loud noises and touch

being physically immobile

which signs and symptoms would the nurse observe in clients with anorexia nervosa? cachexia purging diarrhea hypertension lanugo

cachexia, purging, lanugo

which antiseizure medication would the nurse identify as being used to stabilize a client's mood by suppressing mania associated with BPD? lithium quetiapine ziprasidone carbamazepine divalproex sodium

carbamazepine, divalproex sodium

When planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take? check on client frequently keep the client's room lights dim address the client in a loud, clear voice restraint the client during periods of agitation

check on the client frequently

which foods should the client receiving MAOI avoid?

cheese, beer, and products with chocolate

during an admission interview, a client is expansive and distractible and demonstrated a fragmented, pressured, nonsequential pattern of speech. which communication technique would the nurse use?

closed questions

which medications is most likely to cause metabolic side effects (weight gain, elevated lipid and blood glucose levels)?

clozapine, olanzapine

an older adult seems to make up stories to fill in for memory lapses. which behavior is the client displaying?

confabulating

which strategy would the nurse use to help a depressed, withdrawn client who exhibits sadness through nonverbal behavior?

cope with painful feelings by sharing them

which term describes the disturbance in mood and affect seen in clients who are depressed?

dysphoric

which factor is related to safety when discussing standards for involuntary admission to a mental health facility? mental illness severe disability currently cutting needs treatment

currently cutting

the serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. which assessment findings would the nurse expect? elevation in mood decreased coordination vomiting diarrhea decreased mania

decreased coordination, vomiting, diarrhea

which term would the nurse use to describe the thought processes of a client who insists that they are the commander of an alien spaceship despite repeated reality orientation?

delusion

which clinical manifestations would the nurse assess for in a client experiencing marijuana withdrawal? depression chills red eyes abdominal pain increased appetite

depression, chills, abdominal pain

which assessment finding would the nurse observe in a client with schizoid personality disorder?

detached and socially distant

which actions would be included in the safety plan for a woman in crisis, who is emotionally and physically abused by her husband? limiting contact with the abuser determining a safe place to go in an emergency memorizing the domestic violence hotline number obtaining a bank loan to finance leaving the abuser arranging to a family member to assist in her leaving

determining a safe place to go in an emergency, memorizing the domestic violence hotline number

which initial action would the nurse plan to take for a newly admitted client diagnosed with bipolar I disorder, manic episode?

encourage increased nutritional intake

which benefit is provided by milieu therapy? availability of individual and family therapy positive reinforcement to reduce guilt revelation of unconscious conflicts and fantasies environment provides structure, routine, and security

environment provides structure, routine, and security

which short-term client outcome would be priority for a client who has attempted suicide? strengthening coping skills establishing a no-suicide contract learning problem-solving techniques recognizing why suicide was attempted

establishing a no-suicide contract

which additional clinical manifestation would the nurse monitor for in a client with GAD who presents with restlessness and fatigue?

excessive worry

which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?

exhibits lack of empathy for others

which behavior would the nurse observe in a client who has a histrionic personality disorder?

extroverted and dramatic

Which primary purpose foes the DSM-5 serve?

facilitates classification of mental disorders and guides the determination of diagnosis

which approach would the nurse use to help a client with bipolar disorder who is aggressive and disruptive in group and social settings develop social skills?

facilitating one-on-one interactions

which type of sexual disorder describes a client who has a sexual obsession with shoes?

fetishistic

which term is used to document the client's affect, which was observed during the mental status assessment? depressed flat cooperative resistive

flat

which guideline would the nurse consider when caring for clients who are at risk for suicide?

formal suicide plans increase the likelihood that a client will attempt suicide

which substance can cause life-threatening dysrhythmias when inhaled? glue gasoline nicotine cannabis paint thinner

glue, gasoline, paint thinner

which long-term outcome would the nurse use for a child who has conduct disorder?

has no physically aggressive episodes for 3 months

which feeling is a depressed, suicidal client most likely to verbalize? helplessness hypervigilance isolation indecisiveness hopelessness dominance

helplessness, isolation, hopelessness

which priority approach would the nurse take for a newly admitted client who is found to be experiencing command auditory hallucinations?

identifying the content of the messages in the auditory hallucinations

which behavior is most typical for clients with borderline personality disorder? arrogant eccentric impulsive dependent

impulsive

which rationale explains why the client who is displaying hyperactive and manic behaviors with flights of ideas is not eating?

is too busy to take time to eat

which term or phrase would the nurse chart about thought processes to describe a client diagnosed with schizophrenia who says, "Yes, it's March. March is Little Women. That's literal, you know"?

loose associations

which behavior is the client displaying when pretending to be ill?

malingering

which factor would precipitate a client's use of confabulation?

marked memory loss

an obviously upset client pushes ahead of the other clients and states, "I had an argument with my daughter, and now I'm tense, and anxious, and angry." Which level of anxiety is the client experiencing?

moderate moderate- focused on one part of reality but is unable to grasp the total picture mild- individual is cognizant of all aspects of reality but has "butterflies" panic- individual is no longer in contact with reality, is unable to make decisions, has impaired judgement, and is dysfunctional severe- lose touch with reality and have a feeling of impending doom, which tends to immobilize them

which term describes the client's use of made-up words that have no meaning to other people?

neologisms

which substance would pose the greatest risk of addiction for clients attending an alcohol rehabilitation program? heroin cocaine nicotine phencyclidine

nicotine

which intervention is the most important for a client who is diagnosed with bulimia nervosa? watch for pilfering and hoarding of food encourage eating meals in the public dining area assess for mood swings after eating observe for amount consumed and purging

observe for amount consumed and purging

which interventions would the nurse implement when a client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit? obtain vital signs assess for suicidal thoughts institute continuous monitoring initiate a therapeutic relationship inspect the bandages for bleeding say "you have so much to life for"

obtain vital signs, assess for suicidal thoughts, institute continuous monitoring, initiate a therapeutic relationship, inspect the bandages for bleeding

which behaviors describe an individual with cluster A personality disorder?

odd and eccentric

place the clients in order from highest risk for life-threatening physiological withdrawal to the one with the lowest risk older adult who is withdrawing from alcohol an adolescent withdrawing from cocaine young adult withdrawing from long-acting benzo middle aged adult who is withdrawing from marijuana

older adult, benzo, cocaine, marijuana

which universal characteristic is seen in children with ADHD?

overreaction to stimuli

a hostile client with the diagnosis of schizophrenia, says, "the voices are saying that they are going to poison me because I'm bad." which type of schizophrenic behavior is the client displaying?

paranoid

which characteristic is associated with anorexia nervosa? manic rebellious hypoactive perfectionistic

perfectionistic

which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"?

persecution

what is the correct order of phases a client experiences in the event of a change in body image?

shock, withdrawal, acknowledgement, acceptance, rehabilitation

which interpretation would the nurse make about a depressed client with mild suicidal ideation who has no plan, but has adequate family support and attends church regularly? should be at no risk for suicide warrants one-on-one observation warrants placement in a seclusion room should be reassessed at intervals regarding suicidal intent

should be reassessed at intervals regarding suicidal intent

which description is correct for Alzheimer disease?

slow, relentless deterioration of the mind

a client who is addicted to heroin has major surgery. afterward, the client received methadone. which purpose does the methadone serve?

switches the user from illicit opioid use to use of a legal drug

which initial action would the nurse take for a client with bipolar I disorder, manic episode who becomes loud and vulgar and disturbs the other clients?

take the client to a large, quiet area to walk

a client monopolizes the group therapy discussion and the other group members become inattentive. which intervention is best? gently telling the client that they are taking up too much of the group's time saying nothing and waiting for one of the group members to interrupt the monopolizer thanking the client for sharing and asking other group members to contribute confronting the client by stating that the group is not really interested in their topic

thanking the client for sharing and asking other group members to contribute

which assessment finding is associated with depression? the client has islands of intact memory the client has impaired recent and remote memory the client has impaired recent and immediate memory the client needs step-by-step instructions for simple tasks

the client has islands of intact memory

which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa?

the client has near ideal weight and behavior can seem normal

which situation would indicate the need for naltrexone to be administered?

to decrease the recovering alcoholic's desire to drink

which purpose is the focus of milieu therapy?

to manipulate the surroundings to facilitate positive changes in behavior

which rationale explains the function of obsessions and compulsions for a client with OCD?

unconscious control of unacceptable feelings

which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders? emotional cause feeling of illness restriction of activities underlying pathophysiology

underlying pathophysiology

which action would the nurse take to establish trust in a depressed client?

visit frequently for short periods with the client each day