Unit 7 NCLEX

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?

hypertension, disorientation, and hallucinations

The nurse is caring for a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis?

makes excuses for not leaving the house

A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

no rapids heart beats or anxiety - Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

place client on one-to-one suicide precautions

The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term?

psychodrama

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?

re-experiencing recollections of the trauma

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, and providing acknowledgement and feedback.

Fluoxetine (Prozac) is prescribed for the client, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?

take medication in the morning when I first arise

The nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

termination phase

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 do not share your belief."

A client taking lithium carbonate (Lithobid) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L. The nurse knows that this level is which?

toxic - The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A level of 3 mEq/L indicates toxicity.

The nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is which?

Ping-pong

In planning activities for the depressed client, especially during the early stages of hospitalization, which is best?

Encourage the client to participate in a structured daily program of activities.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

Which is the best rationale for using group therapy as an accepted way of treatment of clients in the milieu?

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

The false belief that one is being singled out for harm by others

The nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

WBC - Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia.

Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?

aversion therapy

The nurse is assisting in a group therapy session. During this session the members are identifying tasks and boundaries. The nurse understands that these activities are characteristic of which stage of group development?

beginning phase

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior?

client is displaying typical behaviors of the termination stage

A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.

figs, yogurt, aged cheese - avoid foods high in tyramine - it is a MAOI - Eating these foods could trigger a potentially fatal hypertensive crisis.

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.

A client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of bupropion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which?

seizure activity

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 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