Exam 2 NRS 211
The prescriber orders Clindamycin Phosphate 500 mg IVPB q8h. The label for the drug reads Clindamycin Phosphate 900 mg per 2 ml. How many ml would the nurse add to a 50 ml bag of 5%D5W? Place a zero in front, if a decimal answer. Round to 100th place.
1.11
The nurse is to initiate IV therapy for a client with dehydration. The order is for 1000 ml D5 ½ NS to run at 200 ml per hour for one liter. The tubing delivers 15 drops per ml. At what rate will the nurse regulate the IV (drops/minute)?
50
A client is scheduled for electroconvulsive therapy and is in the pretreatment evaluation process. Which of the following orders would the nurse question? A. Administer succinylcholine. B. Inform client to fast after midnight the day before the procedure. C. Obtain a complete metabolic panel and electrocardiography. D. Obtain baseline of vital signs.
???? Probably A, maybe C???
A client is admitted involuntarily. The nurse observes the client starring out the four-story window and replying to voices that the nurse is unable to see/hear. What is the most important initial response by the nurse? A. "Are you thinking of jumping out the window?" B. "Who are you talking with?" C. "Why are you looking outside?" D. "Would you like a PRN medication?"
A. "Are you thinking of jumping out the window?"
A client with bipolar disorder is prescribed lamotrigine. After educating the client on this medication, the nurse determines that the education was successful when the client states which of the following? A. "I need to notify my health care provider if I develop a skin rash." B. "I need to have my bold tested about once a month." C. "I have to watch how much salt I use every day." D. "This drug can affect my liver function."
A. "I need to notify my health care provider if I develop a skin rash."
A client asks the nurse if he needs to alter any of his activities because he is taking lithium carbonate. Which of the following responses would be most appropriate? A. "Increase your salt intake if an activity causes you to perspire heavily." B. "Wear sunscreen when you are going to be outdoors in the summer." C. "Drink less fluid than usual now that you are taking this drug." D. "No changes are necessary for strenuous activities you do outdoors."
A. "Increase your salt intake if an activity causes you to perspire heavily."
While assessing a client thought to have a factitious disorder, the nurse asks the client to describe when she felt nurtured as a child. Which response would the nurse interpret as supporting the client's diagnosis? A. "The only time I ever felt loved was when I was sick enough to miss school." B. "I never felt loved when I was growing up." C. "I felt loved when my father apologized for spanking me so hard." D. "The only time I felt loved was when I made the honor roll at school."
A. "The only time I ever felt loved was when I was sick enough to miss school."
The client with schizophrenia is prescribed Clozapine. After educating the client and family, the nurse determines that the teaching was successful when they make which statement? A. "We need to make sure that his blood count is checked at least weekly." B. "He might develop toxic levels, if he becomes dehydrated." C. "He needs to have an EKG periodically." D. "We need to watch to make sure that he doesn't lose too much weight."
A. "We need to make sure that his blood count is checked at least weekly."
A client with bipolar disorder is started on Valproic Na. Which laboratory studies should be monitored regularly? A. AST/ALT and LDH B. Creatine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium
A. AST/ALT and LDH
A nurse is meeting with a client who is being discharged after hospitalization for depression with suicidal ideation. Based on knowledge of the warning signs for suicide, the nurse should plan to advise the client to seek help if experiencing which signs? Select all that apply. A. Acting impulsively B. Currently married C. Hopelessness D. Increasing alcohol use E. Sadness
A. Acting impulsively C. Hopelessness D. Increasing alcohol use E. Sadness
When assessing a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." The nurse documents this finding as indicative of which of the following? A. Anhedonia B. Dysthymic disorder C. Delusion D. Psychosis
A. Anhedonia
A client diagnosed with bipolar disorder has sleep disturbance. Which intervention should the nurse implement initially? A. Assess normal sleep patterns. B. Discourage napping during the day. C. Encourage regular bedtime hours. D. Teach relaxation exercises
A. Assess normal sleep patterns.
A client diagnosed with an anxiety disorder tells a nurse that being in crowds creates thoughts of loosing control and the need to hurriedly leave. What should the nurse recommend as an effective, nonpharmacological therapy for managing the client's symptoms of anxiety? A. Cognitive behavioral therapy (CBT) B. Electroconvulsive therapy (ECT) C. Family systems therapy D. Psychoanalytical therapy
A. Cognitive behavioral therapy (CBT)
A nurse is assessing the mental state of a client diagnosed with schizophrenia. Which symptoms is the nurse most likely to assess? Select all that apply. A. Delusions B. Compulsive behavior C. Dystonias D. Incongruous affect E. Poor concentration
A. Delusions D. Incongruous affect E. Poor concentration
A nurse is working with a client diagnosed with somatic symptom disorder. Which would the nurse identify as the most difficult aspect of providing care to this client? A. Developing the therapeutic communication B. Managing the client's pain C. Monitoring the client's treatment plan D. Relieving the clients anxiety
A. Developing the therapeutic communication
A client diagnosed with paranoid schizophrenia has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. What is the initial nursing intervention for this client? A. Ensure a safe environment for him and others B. Give him an injection of chlorpromazine C. Order him to attend group therapy D. Place him in seclusion
A. Ensure a safe environment for him and others
When a client experiences a manic episode, the nurse would expect to assess which of the following? Select all that apply. A. Flight of ideas B. Grandiosity C. Hypersomnia D. Pressured speech E. Psychomotor agitation
A. Flight of ideas B. Grandiosity D. Pressured speech E. Psychomotor agitation
Which of these manifestations should a nurse expect to assess in a client admitted with major depression? A. Indecisiveness and decreased appetite. B. Intolerance of being alone and lability. C. Distractibility and mistrust. D. Dependency and emotional detachment.
A. Indecisiveness and decreased appetite.
The client has been treated for loss of control with Haldol (Haloperidol) 2 mg IM q 1h until sedated. The nurse notes that the client is lethargic, confused, and has a high temperature, with increased blood pressure. The nurse compares the change in the client's status is most likely related to: A. Neuroleptic Malignant Syndrome B. Serotonin Syndrome C. Therapeutic effects of the medication D. The signs and symptoms of the disease process
A. Neuroleptic Malignant Syndrome
A nurse is making a home visit for an adolescent who attempted suicide. Which behavior should alert the nurse that the adolescent still has suicidal intent? A. Planning to give his CD collection to his girlfriend. B. Stating that he is not eager to go back to school. C. Preferring to eat his meals while watching television. D. Telling his parents that he doesn't want to talk about the attempt.
A. Planning to give his CD collection to his girlfriend.(She needs to update this question CDs!?)
A client diagnosed with Generalized Anxiety Disorder (GAD) states, "I have learned that the best thing I can do is to forget my worries." How would the nurse evaluate this statement? A. The client needs encouragement to verbalize feelings. B. The client's coping skills have improved. C. The client is developing better insight. D. The client's treatment has been successful.
A. The client needs encouragement to verbalize feelings.
The nurse is making a home visit to a client who is diagnosed with dysthymic disorder. When developing this client's plan of care, which of the following would the nurse need to keep in mind? A. The client's symptoms are less intense than with major depression. B. The client's condition is considered to be of a shorter duration. C. The client typically experiences an elevated mood. D. The client experiences symptoms that are intermittent.
A. The client's symptoms are less intense than with major depression.
You are a nurse working with a Crisis Intervention Hotline (telephone) and a client threatens to commit suicide. Which is the priorityresponse by the nurse? A. "Have you attempted suicide before?" B. "How will you carry out this plan?" C. "What happened to make you so desperate?" D. "What will you accomplish by taking your life?"
B. "How will you carry out this plan?"
The nurse implemented the nursing intervention, teaching: medication for a client who has recently been prescribed Propranolol, as part of the treatment regimen for panic disorder. Which of these statements, if made by the client, would distinguish that learning had taken place? A. "I could get a fast pulse and/or high blood pressure from Inderal." B. "I take Inderal for the physical symptoms of my anxiety." C. "I take Inderal to reduce my psychological response to stress." D. "I must be on Inderal for 2-6 weeks before it will work."
B. "I take Inderal for the physical symptoms of my anxiety."
The nurse implemented the nursing intervention, teaching: medication for a client who has recently been prescribed Propranolol as part of the treatment regimen for panic disorder. Which of these statements, if made by the client, would distinguish that learning had taken place? A. "I could get a fast pulse and/or high blood pressure from Inderal." B. "I take Propranolol for the physical symptoms of my anxiety." C. "I take Propranolol to reduce my psychological response to stress." D. "I will have to be on Propranolol for 2-6 weeks before it will work."
B. "I take Propranolol for the physical symptoms of my anxiety."
A client tells the nurse she has bugs in her brain and asks the nurse if she can see them. Which of the following responses by the nurse is most therapeutic? A. "No, I don't see any bugs. Are you seeing bugs or hearing unusual sounds or voices?" B. "No, I don't see any bugs. That sounds scary for you." C. "You have a thought disorder and only think you have bugs in your brain. There really aren't any. You don't have to worry because we would give you medicine for any medical problems." D. "Your thinking is a little illogical. I wouldn't be able to see bugs if they were inside your brain. Would you like to talk more about this?"
B. "No, I don't see any bugs. That sounds scary for you."
A client comes to the emergency department because he thinks he is having a heart attack. Further assessment determines that the client is not having a heart attack, but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to use? A. "Are you feeling much better now that you are lying down?" B. "What did you experience just before and during the attack?" C. "Do you think you will be able to drive home?" D. "What do you think caused you to feel this way?"
B. "What did you experience just before and during the attack?"
A client diagnosed with major depression is admitted to an inpatient psychiatric unit. The nurse enters the client's room and initiates interaction with the client. When talking with the client, which approach would be least appropriate? A. Quit and empathetic manner B. Animated and cheerful manner C. Matter of fact manner D. Respectful and direct manner
B. Animated and cheerful manner
The nurse would recognize that which of the following signs/symptoms are indicative of anticholinergic side effects most often associated with typical antipsychotic medications? A. Agitation, pacing, slurred speech, and sedation B. Blurred vision, constipation, dry mouth, and urinary hesitancy C. Double vision, insomnia, headache, and urinary frequency D. Tremors, spasms of the tongue, pacing, and shuffling gait
B. Blurred vision, constipation, dry mouth, and urinary hesitancy
The nurse is caring for a client with bizarre behavior and delusions that the client is the mayor of the town. Which of the following actions by the nurse would represent appropriate care of this client? A. Avoid focusing on the meaning of feelings provoked by the delusional content B. Call the client by name, state the nurses' name, identify, hospital and location C. Call the client, Mayor and discuss politics to establish rapport with the client D. Tell the client who the Mayor is and that it is not the client
B. Call the client by name, state the nurses' name, identify, hospital and location
A client with bipolar disorder is prescribed lithium to stabilize his mood. The client comes into the mental health clinic to have his blood levels tested. The level comes back as 1.8 mEq/L. What symptoms would the nurse expect to see in this client? A. Abdominal pain, dysuria, fever B. Coarse hand tremors, EKG changes, and mental confusion C. Nausea, vomiting, and muscle weakness D. Severe hypotension, seizures, and ataxia
B. Coarse hand tremors, EKG changes, and mental confusion
The nurse assesses a client with schizophrenia having a dystonic reaction. Which agent would the nurse expect to administer A. Aripiprazole B. Diphenhydramine C. Risperidone D. Propranolol
B. Diphenhydramine
A client with bipolar disorder, prescribed lithium, has a blood level of 1.8 mEq/L. What symptoms would the nurse expect to see in this client? A. Abdominal pain, dysuria, fever B. EKG changes, severe diarrhea, and muscle twitching C. Nausea, vomiting, and muscle weakness D. Severe hypotension, seizures, and ataxia
B. EKG changes, severe diarrhea, and muscle twitching
A group of students is reviewing information about social anxiety disorder in preparation for an oral class presentation. Which of the following would the students expect to include when describing a person with this condition? Select all that apply. A. Openly speak up in crowds to reduce fear B. Fear that others will judge them negatively C. Are insensitive to other's criticism D. Demonstrate a distorted view of their own strengths E. Exaggerate personal flaws
B. Fear that others will judge them negatively D. Demonstrate a distorted view of their own strengths E. Exaggerate personal flaws
The nurse is performing an assessment on a client diagnosed with Bipolar I. Which of the following findings should the nurse anticipate? A. Episodes of hypomania and dysthymia B. Flight of ideas and pressured speech on mental status exam C. Lack of motivation and lack of productive speech D. Periods of feeling depressed most days for 2 years
B. Flight of ideas and pressured speech on mental status exam
A nurse is assessing a client with major depressive disorder who has been taking amitriptyline for one week. Which outcome should the nurse expect? A. Rapid improvement within 60 minutes 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. Greater risk of attempting suicide as affect and energy improve.
A nurse is developing an education plan for a client with schizophrenia. Which method would the nurse use to be most effective? A. Engaging the client with trial-and-error learning. B. Having the client write down information directly after receiving it. C. Asking the client questions that encourage the client to guess the correct answer. D. Using visual aids that are very colorful and full of descriptive graphic images.
B. Having the client write down information directly after receiving it.
A client with bipolar disorder is prescribed lithium carbonate to stabilize his mood. The client's blood level comes back as 1.8 mEq/L. What symptoms would the nurse expect to assess in this client? A. Abdominal pain, dysuria, fever B. Incoordination, tinnitus, and increasing tremor C. Nausea, vomiting, and muscle weakness D. Severe hypotension, seizures, and ataxia
B. Incoordination, tinnitus, and increasing tremor
The nurse in the emergency department interviews a client and finds that the client was with a dear friend at the senior center when the friend suddenly died. The client reports a variety of concerns and casually mentions that she can't complete the forms because she cannot see since yesterday's events at the senior center. Which of the following analyses would the nurse consider? A. Cognitive deficits B. La Belle Indifference C. Psychomotor Retardation D. Somatic Delusions
B. La Belle Indifference
A client says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment? A. Client's educational background. B. Lethality of the method and availability of means. C. Quality of the client's social support. D. Client's insight into the reasons for the decision.
B. Lethality of the method and availability of means.
Client teaching for lamotrigine should include which of the following? A. Eat a well-balanced diet to avoid weight gain. B. Report any rashes to your doctor immediately. C. Take each dose with food to avoid nausea. D. This drug may cause psychological dependence.
B. Report any rashes to your doctor immediately.
A female client with schizophrenia has been prescribed chlorpromazine. The client calls the mental health clinic and tells a nurse that her urine has become dark in color but that she has no other urinary symptoms. What does the nurse tell the client? A. That this indicates medication toxicity B. That this is an expected side effect of the medication C. To increase the intake of acid ash foods and liquids D. To seek treatment for a urinary tract infection
B. That this is an expected side effect of the medication
The nurse is caring for a client diagnosed with Paranoid Schizophrenia. Orders from the psychiatrist include 100 mg chlorpromazine STAT and then 50 mg 2x day; 2 mg benztropine 2x day prn. Which of the following assessments by the nurse would convey a need for benztropine? A. The client complains of a sore throat. B. The client develops tremors and a shuffling gait. C. The client's level of agitation increases. D. The client's skin has a yellowish color
B. The client develops tremors and a shuffling gait.
What is the best goal for a client learning a relaxation technique? A. The client will confront the source of anxiety directly. B. The client will experience anxiety without feeling overwhelmed. C. The client will report no episodes of anxiety. D. The client will suppress anxious feelings.
B. The client will experience anxiety without feeling overwhelmed.
What is the best goal for a client learning a relaxation technique? the client will: A. The client will confront the source of anxiety directly. B. The client will experience anxiety without feeling overwhelmed. C. The client will report no episodes of anxiety. D.The client will suppress anxious feelings.
B. The client will experience anxiety without feeling overwhelmed.
A client who is diagnosed with mania is touching other clients on the unit, speaking in a loud voice, labile, and loosely associated. Which of these manifestations should a nurse focus on first? A. communication B. intrusiveness C. mood D. tone of voice
B. intrusiveness
A client with generalized anxiety disorder states that he is worried about his job. He never feels like he has control over his responsibilities, even though he puts in extra hours. He adds that he is afraid he will be fired. Which response by the nurse is most therapeutic? A. "It sounds to me like you're doing a good job." B. "Your worries are a feature of your anxiety disorder. Tell yourself that you have nothing to worry about." C. "Has something changed at work that is causing you to worry?" D. "Why do you think you'll be fired?"
C. "Has something changed at work that is causing you to worry?"
A nurse is caring for a client with major depressive disorder who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks she nurse about this medication. What is an appropriate response by the nurse? A. "Succinylcholine will decreas3 anxiety levels that you might experience with ECT." B. "Succinylcholine will enhance the therapeutic effects of the ECT treatment." C. "Succinylcholine is given to reduce muscle movements during ECT." D. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during ECT."
C. "Succinylcholine is given to reduce muscle movements during ECT."
A nurse is planning care for a client scheduled for electroconvulsive therapy (ECT). Which planned action by the nurse is unsafe when caring for this client? A. Administering a short-acting barbiturate prior to the procedure. B. Monitoring vital signs before, during, and after the procedure. C. Administering succinylcholine after the procedure to decrease recovery time. D. Educating the client that experiencing confusion, tiredness, headache, and back ache after the procedure is normal.
C. Administering succinylcholine after the procedure to decrease recovery time.
The nurse on a psychiatric unit is caring for a hospitalized depressed client who has a poor response to medications. The client will be started on amitriptyline. Which test does the nurse anticipate will be ordered prior to starting the client on amitriptyline? A. CBC B. EEG C. EKG D. Liver function profile
C. EKG
Which of the following assessments would validate the diagnosis of generalized anxiety disorder (GAD)? Select all that apply. A. Excessive worry about items difficult to control. B. Expansive mood with pressured speech. C. Feeling "on edge." D. Hypersomnia. E. Muscle tension.
C. Feeling "on edge."
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that she stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? A. Sore throat B. Photophobia C. Hand tremor D. Constipation
C. Hand tremor
A nurse assesses a client with the admitting diagnosis of bipolar disorder: mania. Which of the following symptoms presented by the client requires the nurse's immediate intervention? A. Grandiose delusions of being a royal descendent of King Arthur B. Incessant talking that includes sexual innuendoes and teasing of the staff C. Nonstop physical activity and poor nutritional intake D. Outlandish behaviors and inappropriate dress
C. Nonstop physical activity and poor nutritional intake
A female client is brought to the emergency department by her brother, who reports that she became very agitated and "started hallucinating." Further assessment reveals tachycardia, incoordination, vomiting, and diarrhea. The brother states that his sister is taking paroxetine for depression. Which of the following would the nurse most likely suspect? A. Neuroleptic malignant syndrome B. Acute dystonic reaction C. Serotonin syndrome D. Hypothyroidism
C. Serotonin syndrome
The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw wringing his hands, and trembling. His speech is high pitched and random; he is preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse analyzes his anxiety level as A. Mild B. Moderate C. Severe D. Panic
C. Severe
A nurse is caring for a client newly admitted for treatment of major depression and malnutrition. Which is the best nursing intervention for this client now? A. Ask the health care provider for a nutritional consultation. B. Instruct the client about the importance of eating. C. Sit with the client during meals and snacks. D. Weigh the client at the same time each morning.
C. Sit with the client during meals and snacks.
Karl has schizophrenia. He has been arranging his clothes in his drawer repeatedly for the past few hours. This is called: A. Catatonic excitement B. Echopraxia C. Stereotypy D. Waxy Flexibility
C. Stereotypy
A client with anxiety is beginning treatment with Lorazepam. What is most important for the nurse to assess? A. The client's family and social support B. The client's motivation for treatment C. The client's use of alcohol D. The client's use of coping mechanisms
C. The client's use of alcohol
The nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, "I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. Men constantly want to have sex with me." Which of the following is consistent with this assessment? A. irritable mood B. euthymic mood C. expansive mood D. dysthymic mood
C. expansive mood
A female client tells the nurse that she has been worried and tearful lately because of pressures at work. She states, "My boyfriend tells me that it's "stress" and "anxiety", but doesn't everyone have that? What is anxiety anyway?" Which of the following responses gives the best information about the nature of anxiety? A. "Anxiety is an abnormal response to everyday stress." B. "Anxiety is a normal response to everyday stress." C. "Anxiety is a physiologic response to stress." D. "Anxiety is a sense of psychological distress."
D. "Anxiety is a sense of psychological distress."
Which of theses questions should a nurse ask when assessing a client for evidence of bipolar disorder, mania A. "Have you lost interest in your friends?" B. "Are you frequently bored with everything?" C. "Is it difficult to get started in the morning?" D. "Do you have difficulty focusing your thoughts?"
D. "Do you have difficulty focusing your thoughts?"
You are a nurse working with a Crisis Intervention Hotline (telephone). A client reports on the phone, "I have just taken 50 clonazepam tablets to kill myself." Which of the following is the priority response by the nurse? A. "Why do you think you have no reason to live?" B. "How do you feel about what you have just done?" C. "I'm sure things are not as bad as they seem to you now." D. "Please stay on the phone with me so we can talk about your feelings."
D. "Please stay on the phone with me so we can talk about your feelings."
A client in a locked mental health unit approaches a nurse and says, "I don't belong here. Please try to get me out." Which of the following responses is appropriate A. "Why do you feel that you need to leave?" B. "We are here to help you and give you the care that you need right now." C. "Try to take some deep breaths and I'm sure you'll feel better." D. "You feel that you don't belong here?"
D. "You feel that you don't belong here?"
When assessing a client for possible disordered water balance, the nurse checks the client's urine specific gravity. Which result would lead the nurse to suspect that the client is experiencing severe disordered water balance? A. 1.020 B. 1.011 C. 1.005 D. 1.002
D. 1.002
A nurse in an acute mental health facility is receiving report. Which of the following four clients should the nurse assess first? A. A client who doesn't recognize familiar people. B. A client who can't verbalize their needs. C. A client who is awake and disoriented at night. D. A client who is experiencing delusions of persecution.
D. A client who is experiencing delusions of persecution.
The evening nurse receives report on the following four clients. When doing first rounds, which client should the nurse see first? A client with A. A client with Bipolar I on Topiramate with a documented mild weight loss. B. A client with Catatonic schizophrenia that had ECT today and is experiencing memory loss. C. A client with chronic confusion reporting that the mental health technician is a spy for the CIA. D. A client with depression on Phenelzine with a blood pressure baseline of 120/80 and now, 138/88.
D. A client with depression on Phenelzine with a blood pressure baseline of 120/80 and now, 138/88.
A client who has been taking an antipsychotic medication for two weeks begins pacing and walking throughout the unit. The client tells the nurse that he "cannot sit still." The nurse documents this finding as which of the following? A. Akinesia B. Dystonia C. Pseudoparkinsonism D. Akathisia
D. Akathisia
A client with anxiety is experiencing the fight or flight response. Which body adaptation occurs during fight or flight? A. A decrease in blood clotting ability B. A decrease in heart rate and blood pressure C. An increased immune response and digestion D. An increase in blood flow to the muscles
D. An increase in blood flow to the muscles
The nurse is planning a series of group therapy sessions with clients diagnosed with somatic symptom disorder. The nurse plans to focus the sessions on which of the following as a priority? A. Causes of medical illnesses B. Positive self-talk C. Side effects of medications D. Assertiveness skills
D. Assertiveness skills
A client with Generalized Anxiety Disorder is prescribed Buspirone to control extreme restlessness and irritability. During the client teaching, the nurse should inform the client of which common side effect? A. Arrhythmias B. Ataxia C. Confusion D. Drowsiness
D. Drowsiness
A nurse is caring for a client who is taking Olanzapine. In which priority order, should the laboratory test results in need of attention be addressed? Na 120 mEq/L CPK 122 mcg/L BUN 24 mg/dL WBC 2400 million cells/mcL K 2.9 mEq/L Chloride 101 mEq/L A. BUN, K, Na B. Na, K, WBC C. WBC, K, CPK D. K, Na, WBC
D. K, Na, WBC
The nurse is performing an assessment on a client with Major Depression. Which of the following assessment findings should the nurse anticipate? A. Decisiveness B. Incessant talking C. Neologisms D. Psychomotor retardation
D. Psychomotor retardation
A client has begun taking bupropion as an antidepressant agent. The nurse monitors this client for which adverse effect that indicates the client is taking an excessive amount of medication? A. Constipation B. Dizziness when getting upright C. Increased weight D. Seizure activity
D. Seizure activity
Which of the following medications would the nurse recognize as specific for the client diagnosed with obsessive-compulsive anxiety disorder? A. Lorazepam B. Benztropine C. Amitriptyline D. Sertraline
D. Sertraline
A nurse is caring for a client experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which nursing intervention is best? A. Warn the client that further disruption will result in seclusion. B. Ignore the client's behavior, since it is consistent with her illness. C. Ask the client to recommend consequences for disruptive behavior. D. Set limits on the client's behavior and be consistent in approach.
D. Set limits on the client's behavior and be consistent in approach.
A female client who has been unemployed secondary to her anxiety disorder states that she would like to have a job where she is alone and no one needs to evaluate her work. The nurse interprets these comments as an indicator of which of the following? Answers: A. Agoraphobia B. Obsessive-compulsive disorder C. Panic disorder D. Social phobia
D. Social phobia
A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions? A. Grandiose B. Persecutory C. Reference D. Somatic
D. Somatic
A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which type of delusions? A. Grandiose B. Persecutory C. Reference D. Somatic
D. Somatic
The initial care plan for a client with Obsessive Compulsive Disorder (OCD) who washes her hands obsessively would include which of the following nursing interventions? A. Explain the client's behavior to her, since she is probably unaware that it is maladaptive. B. Keep the client's bathroom locked so she cannot wash her hands all the time C. Place the client in isolation until she promises to stop washing her hands so much. D. Structure the client's schedule so that she has plenty of time for washing her hands
D. Structure the client's schedule so that she has plenty of time for washing her hands
The client who has been taking quetiapine for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation(s) has occurred? A. Alcohol withdrawal symptoms B. Feelings of guilt C. Rapid heartbeat or anxiety D. Thought disturbances or delusions
D. Thought disturbances or delusions
The client with schizophrenia is being started on Clozapine 100 mg po 2 x day. The nurse implementing medication teaching would include which of the following in the teaching plan? A. Food restrictions that clients must follow B. Lifestyle changes to prevent neuroleptic malignant syndrome (NMS) C. Signs and symptoms of tardive dyskinesia (TD) D. Weekly monitoring of complete blood counts (CBC)
D. Weekly monitoring of complete blood counts (CBC)
The client is on phenelzine and has received medication teaching regarding dietary considerations. Which of the following meal selections would support that learning took place? A. Low-fat yogurt with bananas and raisins B. Pickled herring on a bagel with cream cheese C. Sprouts and avocado on a spinach wrap D. Whole grain cereal with milk and an apple
D. Whole grain cereal with milk and an apple
What is the most frequent reason given by clients for non-compliance with olanzapine therapy? A. fears of side-effects B. gastrointestinal upset C. increases suicidal ideation D. weight gain
D. weight gain
A nurse is meeting with a client who is being discharged after hospitalization for depression with suicidal ideation. Based on knowledge of the warning signs for suicide, the nurse should plan to advise the client to seek help if experiencing: Select all that apply. a. Acting impulsively b. Hopelessness c. Increasing alcohol use d. Talking of wanting to kill oneself e. Hypersomnia
a. Acting impulsively b. Hopelessness c. Increasing alcohol use d. Talking of wanting to kill oneself
