Unit 7 Flashcards NCLEX Prep

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful and think that others may want to hurt you?"

The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

"I cannot promise to keep a secret."

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

Assist in making appropriate referrals.

Which data indicates to the nurse that a client may be experiencing ineffective coping following the loss of her spouse?

Constantly neglects personal grooming

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the health care provider (HCP).

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

Denial

The nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which signs and symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?

Stay with the client at all times.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

Psychomotor retardation and side effects of medication

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

"Let me know if you change your mind, and I'll get you something to eat."

The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

"What leads you to seek help now?"

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client?

Provide authority, action, and participation.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?

The client presents a harm to self.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

The client will participate in the treatment plan.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?

Within a few hours