FINAL EXAM TOPICS

Which of the following statements best describes why the nurse should be educated about client to have intellectual disabilities?

Nurses need to provide quality care for all clients in a variety of settings

A nurse is planning care for a client who has dissociative identity disorder. Which of the following action should the nurse plan to take?

Provide one-on-one, therapeutic interaction and support

A nurse is caring for a client who was brought to the ER following displacement from their home due to a flood. When assessing the client, which of the following clinical manifestations would the nurse anticipate are related to the experience of trauma? SATA a. Anxiety b. Sleep disturbance c. Anger d. Depression e. Hallucinations f. Elevated mood

a, b, c, d

A nurse is caring for a client who is experiencing withdrawal from alcohol. The nurse should use which of the following assessment tools in their treatment for this client? a. AUDIT b. CIWA-AR c. CAGE d. MAST

b. CIWA-AR

A nurse is providing care for an adolescent who sustained injuries in assault. Which of the following actions should the nurse take first? a. Identify the adolescent's coping strategies and skills b. Explore the adolescent's feelings about the assault c. Provide a safe, secure environment for the adolescent d. Provide the adolescent with information on support groups

c. Provide a safe, secure environment for the adolescent

A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the nurse observes that the patient is anxious, fidgeting in their chair, and sweating profusely. Which of the following types of data describes the clients actions? a. Historical b. Secondary c. Subjective d. Objective

d. Objective

A nurse is discussing somatic symptom disorder with a newly licensed nurse. Which of the following should the nurse identify as a risk factor for this disorder?

A history of alcohol use disorder

A charge nurse is discussing illness anxiety disorder with a newly licensed nurse. Which of the following information to the charge nurse include?

Client to have this disorder can experience, suicidal thoughts

A nurse is caring for a client who was recently diagnosed with PTSD. The client asks, "what is the difference between acute stress disorder and PTSD?" Which of the following responses should the nurse make? a. "With acute stress disorder, the traumatic experience and response to it is less severe." b. "PTSD is diagnosed if the symptoms persist for longer than 1 month." c. "PTSD can only be diagnosed if the trauma is experienced firsthand." d. "Acute stress disorder does not involve arousal symptoms or negative alterations in mood."

b. "PTSD is diagnosed if the symptoms persist for longer than 1 month."

A nurse is providing care for a client who has PTSD. The client states "I always have to watch my back!" Which of the following manifestations of PTSD is the client experiencing? a. Anosognosia b. Hypervigilance c. Anhedonia d. Dissociative amnesia

b. Hypervigilance

A nurse is discussing common misconceptions regarding patients who have substance use disorder. The nurse should include which of the following as a possible consequence of a client being labeled by providers as drug seeking? a. The client may realize that their behavior is inappropriate b. The client will ask to see what is written in their chart and sue the provider c. The client may be discharged without getting needed treatment d. The provider may be reprimanded and lose their job

c. The client may be discharged without getting needed treatment

So like three interventions, the nurse should plan to take for the patient experiencing dissociative amnesia

• encourage the client to think positive thoughts • assess the client and distinguishing between anxiety and physical manifestations • Provide relief measures for manifestations. The client is experiencing.

A nurse expect the client may be experiencing dissociative amnesia select three interventions. The nurse should plan to take.

• inform the client that memory loss as a form of coping • provide relaxation techniques to the client when they are experiencing anxiety • encourage the client to hold an object and focus on it

A nurse on an inpatient unit is speaking with a client about the recent diagnosis of depersonalization derealization disorder. The client asked the nurse, "what is the treatment for this disorder?" Which of the following responses should the nurse make?

A combination of psychotherapy and medication is often used

A nurse is caring for a client who seeks care frequently due to fear of having a serious illness. After learning that the laboratory results should know or abnormalities the client begins to hyperventilate. The client is exhibiting manifestations of which of the following disorders?

Illness, anxiety disorder

A nurse is reviewing notes from the interdisciplinary team. Which of the following statements from the child's caregiver suggest that the child might have a learning disorder?

My seven year old child has difficulty with subtraction

A nurse should identify that which of the following factors is a protective factor that prevents younger people from developing addiction? a. Positive relationships b. Married parents c. Living in the Midwest population of the U.S. d. Participating in team sports

a. Positive relationships

A nurse is caring for a client who is hospitalized for gallbladder removal surgery. On their first postoperative day, the client has agitation, a high temperature, increased, respirations, irritability, and confusion. The nurse should recognize that the client may be experiencing withdrawal from which of the following substances? a. Hallucinogens b. Alcohol c. Heroin d. Stimulants

b. Alcohol

A nurse at a community treatment center asks a client about their use of a prescribed anti-psychotic medication that should be taken daily. Which of the following client statements should suggest to the nurse that the client is not adhering to their medication treatment plan?

"I sometimes go a few days without taking my medication."

A nurse on a mental health unit is admitting a client who is shouting at staff and has a history of aggressive behavior. Which of the following statements should the nurse make?

"I will be working with you to help you meet your needs while you are here. What can I help you with now?" The nurse should identify that aggressive behavior is a finding associated with antisocial personality disorder. At this time, the client is angry and wants their needs met. The nurse is showing empathy and collaboration which can neutralize the client's aggression.

A nurse is talking with a client about mental health care and services. The client asks, "What is the difference between psychosis and schizophrenia?" Which of the following responses should the nurse make?

"Psychosis describes conditions where a person loses contact with what is real. Schizophrenia is a mental health illness where the person can show manifestations of psychosis."

A nurse is caring for a client who has schizophrenia. Which of the following questions should the nurse ask during the exploitation phase of the nurse-client relationship?

"Which stress reduction techniques are you finding helpful alongside your medication?"

A nurse is planning care for a client who has acute stress disorder. For each potential nursing intervention, click to specify if the potential intervention is expected, nonessential, or contraindicated for the client. - Repeat vital signs every hour - Ask close-ended questions - Rotate staff as often as possible - Assess for environmental safety risks - Encourage the client to share details regarding trauma - Use screening tools to monitor manifestations

- Nonessential - Contraindicated - Contraindicated - Expected - Contraindicated - Expected

A nurse is caring for a newly admitted client who is concerned about their ability to continue to practice nursing. Admission Note - Day 1: 41-year-old client admitted with substance use disorder. Client was injured several years ago and subsequently developed an addiction to pain medications. Client is an RN and has been employed at a local health care facility on a medical-surgical unit. Nurses' Notes Day 3: Expressing remorse regarding dependence on and misuse of prescription medications. Reports they have diverted narcotics while working but doesn't believe anyone knows about it. States, "I want to get better and take responsibility for my actions. Will I ever be able to work as a nurse again?" For each potential disciplinary action, click to specify if the action is anticipated or unexpected for the client. 1. State board of nursing will investigate 2. Immediate loss of license 3. Enrollment into a monitori

1. Anticipated 2. Unexpected 3. Anticipated 4. Unexpected

A nurse is working with an interdisciplinary disaster response team planning care for a coastal community following a category 5 hurricane. Place the following steps of disaster management in the correct order: - Partner with the client to develop a plan - Determine the resources the client has available to them - Determine the challenges the community is facing - Assess the client's ability to function and cope with the current situation

1. Determine the challenges the community is facing 2. Assess the client's ability to function and cope with the current situation 3. Determine the resources the client has available to them 4. Partner with the client to develop a plan

A nurse is caring for a client in detoxification unit. Admission note Day 1 :55-year-old client admitted with long-standing history of alcohol use disorder. Recently involved in motor vehicle accident and now seeking inpatient detoxification and treatment for alcohol use disorder. Blood alcohol level at time of accident was 0.33 mg/dL. Reports drinking "hard liquor" since age 14. Also states, "I drink about 10 to 12 drinks of vodka a day." Nurse's Note Day 1 0800:Client reports drinking "several shots of vodka yesterday". Tremulousness of hands noted. Client refuses food currently, stating, "I am nauseated." 1600:Assisted client to complete the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) document. Client's score is 32. Complete the following sentence by using the list options 1. The client is at the highest risk for developing: a. moderate withdrawal b. severe withdrawal c. mild with

1. b. severe withdrawal 2. b. CIWA-AR score

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should indicate to the nurse the client is in the mild stage of the disease? a. loss of bladder control b. difficulty planning c. wandering at night d. inability to write

Answer: b Rationale: The nurse should identify the client who has difficulty planning is in the mild stage of Alzheimer's disease. Other manifestations the client can experience in the mild stage include forgetting names of individuals they have just been introduced to, being unable to choose the right word or name, difficulty performing tasks, forgetting material just read, and losing objects. Loss of bowel and bladder control is a manifestation that can occur during the moderate stage of Alzheimer's disease. Wandering at night is a manifestation that can occur during the moderate stage of Alzheimer's disease. Inability to write is a manifestation that can occur during the severe stage of Alzheimer's disease.

A nurse is caring for a client who states, "I have no close friends. I do not go to parties. I can't talk in front of people, and I fear rejection." The nurse should identify that these findings are manifestations of which of the following personality disorders?

Avoidant personality disorder The nurse should identify that a client who has avoidant personality disorder will typically lack close friends, avoid social activities for fear of criticism, and feel anxiety or embarrassment when speaking in front of other people.

A nurse is caring for a client who states they feel like they see themselves from the outside of their body. The nurse should document that the client is experiencing which of the following manifestations?

Depersonalization

A nurse is caring for an adult client who is recently involved in a motor vehicle accident. The client states "I feel strange like I'm outside of my body, watching myself talk" which of the following is the client likely experiencing?

Depersonalization or de realization

A nurse is caring for a client who has been diagnosed with dissociative identity disorder. The client develops an alter personality when discussing the trauma. How should the nurse respond when this occurs?

Display empathetic, listening and keep the client comfortable and safe

A nurse is caring for a client who is sexually assaulted. The client is frustrated because I cannot recall any events or information related to the event. What condition is the client likely experiencing?

Dissociative amnesia

A nurse is caring for a client who reports an extensive history of physical and sexual abuse as a child. The client states "sometimes I do things that I'm not aware of. I see pictures of myself on social media and I'm wearing things that I would never wear, and I am in locations where I would never go. It makes me feel so frustrated" The client is exhibiting manifestations of which of the following disorders?

Dissociative identity disorder

A newly licensed nurse ask the charge nurse on a mental health unit which age groups are impacted by dissociative identity disorder. Which of the following responses should the charge nurse make?

Dissociative identity disorder can be present throughout the lifespan

A nurse is discussing the risk factors for developing a dissociative disorder with a client. Which of the following would place the client at a higher risk for developing dissociative disorder?

Experiencing physical abuse as a child

A nurse is caring for a client who has a new diagnosis of dissociative identity disorder. Which of the following medication should the nurse expect the provider to prescribe?

Fluoxetine, benzodiazepines, or beta blockers

A nurse is providing care to a client who is experiencing a loss of motor strength with no identifiable physical cause. The nurse would expect the client to be diagnosed with which of the following disorders?

Functional neurological symptom disorder

A nurse is caring for a client who has illness anxiety disorder. The client says to the nurse "I don't know what you can do for me. I have seen so many healthcare providers and no one has been able to help." Which of the following responses, should the nurse make?

I can help you learn new coping skills to better manage your symptoms

A nurse in an outpatient clinic is working with a client who has been diagnosed with dissociative amnesia. Which of the following client statements would be an indication that the client is likely to experience an exacerbation of manifestations related to dissociative amnesia?

Last week I learned that I have an aggressive form of skin cancer

A nurse is working at a wellness center and is discussing developmental milestones with the guardians of a two year old child. One of the guardian states "my child does not behave like other children at the park or other play dates. I think there might be something wrong with my child" which of the following is a therapeutic response to the guardians concern?

Let's do a Nuro developmental screening for your child at this visit to investigate your concerns

A nurse is providing education to a client in their partner about dissociative identity disorder. Which of the following information should the nurse include in the teaching?

Manifestations of dissociation may include depersonalization and lack of access to memories

A nurse is caring for a client who states that they are entitled to a single room on the mental health unit and that the nurse is not educated enoguh to care for them. The nurse should identify that this finding is consistent with which of the following personality disorders?

Narcissistic personality disorder The nurse should identify that clients who have narcissistic personality disorder feel a sense of grandiosity and entitlement and often will either devalue or idealize their caregivers.

A nurse is caring for a client who is moving the furniture in the day room into straight rows and complaining about the different colors of clothes the other clients are wearing. The nurse should identify that these findings are consistent with which of the following personality disorders?

Obsessive-compulsive personality disorder The nurse should identify that clients who have obsessive-compulsive personality disorder are preoccupied with order and strict adherence to moral rules.

A nurse is caring for a client who recently experienced a traumatic event and is experiencing flashbacks. Which of the following client findings require immediate follow-up by the nurse? SATA Has sad expression, eyes downcast, and does not react to others trying to speak to them Shared in group therapy session how their job as a law enforcement officer exposes them to many "bad situations, like parents hurting their children and seeing dead people." Overheard another employee saying to client, "Maybe if you weren't always bothering innocent people and trying to give everyone a ticket, you wouldn't be here." Client left area and returned to their room

Overheard another employee saying to client, "Maybe if you weren't always bothering innocent people and trying to give everyone a ticket, you wouldn't be here."

A nurse is planning care for an adolescent who has autism spectrum disorder and he was also experiencing manifestations of depression. Which of the following action should the nurse take?

Refer the adolescent for psychiatric follow up

A nurse is giving a presentation on various types of therapy to a group of staff nurses. Which of the following therapies is the nurse describing when discussing a therapy that uses psychoeducation to change thought patterns?

Schema therapy The nurse should identify that schemas are "patterns of thought," and schema therapy seeks to change those patterns.

A nurse is caring for a client who has dissociative identity disorder. In the morning the client was pleasant and cooperative. However, when the nurse goes to administer lunchtime medications, the client is angry and refuses medication, stating, "I want to die" which of the following action should the nurse take?

Stay with a client and ensure they are safe

Which of the following characteristic should a nurse expect a four year old child who is referred for stuttering?

The child has been experiencing manifestations for the past two years

A nurse is reviewing the plan of care for a client who has ADHD. Which of the following outcomes, could indicate that the interventions have been effective?

The client is more focused and attentive

A nurse on amental health unit is planning care for a client who has borderlien personality disorder. Which of the following goals shoudl the nruse set for the client?

The client will have no emotional outbursts during group therapy for a week. The nurse should identify that the goal for a client who has borderline personality disorder is emotional regulation. This goal is measurable and appropriate.

A nurse is reviwing the medical record of a client who has a personality disorder. The nurse should identify that which of the following findings is a risk factor for the development fo a personality disorder?

The client's needs were not met during childhood. Trauma and neglect in childhood can affect the development of personality disorders.

A charge nurse is preparing an in service for staff nurses about the diathesis stress model. Which of the following information should the charge nurse include?

The model proposes that genetic and biological vulnerabilities emerge under stress. The nurse should identify that the model proposes a theory that genetic and biological vulnerabilities, including personality traits and temperament, emerge under stress. This model uses biological and psychosocial factors to predict the development of a personality disorder.

A nurse is caring for a client with somatic symptom disorder. Which of the following assessment is the nurses priority?

Thoughts of suicide, her self harm

A nurse is evaluating a client for schizophrenia and asks the client about their work, social, and home life. For which of the following reasons should the nurse ask about these topics?

To gather insight into the client's background in order to guide care

A nurse is caring for a client who has somatic symptom disorder and reports frequent abdominal pain. Which of the following responses should the nurse make?

What has worked in the past to relieve the pain?

A nurse is caring for a client. Nurses' Notes Day 1 0900:Client is 65 years old, diagnosed with Parkinson's disease 5 years ago. Family brought client to the emergency department. Client confused to place and time, and unsteady when walking. Nurse notes client is incontinent of urine. Vital Signs Day 1 0905:Temperature 38.2° C (100.7° F)Blood pressure 120/78 mm HgHeart rate 92/minRespiratory rate 16/minSaO2 96% on room air Day 1 1300:Temperature 39° C (102° F)Blood pressure 125/98 mm HgHeart rate 98/minRespiratory rate 16/minSaO2 94% on room air History and Physical Day 1 0830:Previous admission data 6 months ago:Client previously admitted 6 months ago with darkening of urine. Taking Carbidopa 25 mg and Levodopa 100 mg three times daily.Creatinine 1.2 mg/dL (0.7 to 1.3 mg/dL)Blood urea nitrogen (BUN) 18 mg/dL (10 to 20 mg/dL)Client discharged as urine discoloration is an effect of carbidopa/levodopa therapy and

When recognizing cues of dementia related to Parkinson's disease, the nurse should recognize that urinary incontinence can be a clinical indicator of evolving dementia associated with this chronic condition. The client's elevated temperature can cause increased confusion and agitation.

A nurse is at a clinic screening clients for trauma. The nurse should identify that which of the following factors increases a client's risk for developing a trauma-related disorder? a. The client has a history of physical abuse b. The client belongs to a marginalized group c. The client was active military during the Iraq war d. The client is from a large family e. The client is male f. The client has stable income

a, b, c

A nurse is preparing educational material for guardians on trauma prevention and developing childhood resilience. Which of the following techniques should the nurse include? SATA a. Foster a hopeful perspective of the future b. Encourage development of thinking and learning c. Provide secure and supportive relationships and places d. Ignore tantrums e. Discourage expression of anger f. Insist the child verbalizes emotional needs

a, b, c

A nurse is assigned to triage clients following an explosion at an oil refinery. Which of the following symptoms are consistent with a trauma response involving the SNS? SATA a. Increased heart rate b. Shallow breathing c. Muscle tension d. Immobility e. Anxiety f. Fatigue

a, b, c, e

A community health nurse observes an 8-month-old child being reunited with their parent after being found alone in an automobile. Which of the following responses should the nurse identify as an indication that the child might be experiencing poor attachment? SATA a. The child continues to play with a toy when their parent steps into the room b. The child does not respond when held and embraced by the parent c. The child reaches out to the parent when they enter the room d. The child selects a toy offered them and begins to play while sitting on their parent's lap e. The child cries when the nurse tries to give the child to the parent

a, b, e

A nurse is caring for a client. Nurses' Notes Admission - Day 1: 19-year-old client admitted for evaluation of potential substance use disorder. Client lives with adult parents and is enrolled in college courses leading to an associate degree in accounting. Client regularly attends spiritual services with their father. Client acknowledges that they have been dating the same individual for 18 months, and "we plan to move into together as soon as we have the money." Day 2: 1500:Client revealed during group therapy session that they were physically abused by a family member while they were an adolescent. Also stated, "My mom is depressed and has been taking pills for a long time." Client also acknowledged that their favorite uncle has been "smoking dope and taking pain pills for as long as I can remember." Select the 2 findings that require immediate follow-up. a. Statement regarding clients uncle b. Living arrangement

a, d

A nurse is preparing a teaching for high school students regarding trauma and interpersonal violence. Which of the following statements should the nurse plan to include in the teaching? a. "Interpersonal violence includes physical, sexual, and emotional maltreatment, which are types of trauma." b. "Interpersonal violence are acts of aggression occurs between two adults and is a form of sexual maltreatment." c. "Interpersonal violence occurs most frequently between people who do not know each other." d. "Interpersonal violence is the result of unintentional force and maltreatment against another person."

a. "Interpersonal violence includes physical, sexual, and emotional maltreatment, which are types of trauma."

A nurse is caring for a client following a suicide attempt. Which of the following statements by the nurse reflects a trauma-informed approach? a. "This must be difficult. Can you tell me about what has happened to you?" b. "You are new to the unit. Why are you here?" c. "You sit alone. Do you really want to be here?" d. "You seem in pain, Why did you try to harm yourself."

a. "This must be difficult. Can you tell me about what has happened to you?"

A nurse is working with a local crisis response team to evaluate students following a school shooting. After ensuring the safety of the students, which of the following trauma-informed approaches should the team take next? a. Establish a supportive environment that facilitates trust and transparency b. Provide resources to students for trauma support and recovery c. Explain what trauma is and the symptoms of trauma d. Report any students exhibiting inability to cope with their traumatic event

a. Establish a supportive environment that facilitates trust and transparency

A nurse is developing a plan of care for a 14-year-old client who has a history of child maltreatment. The staff have reported that any time an alarm occurs, the client is found sitting in a closet. Which of the following most accurately describes the client's response? a. Fear conditioning b. Fear extinction c. Self-regulation d. Stress resilience

a. Fear conditioning

A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the nurse learns from the client that they were treated for both asthma and anxiety as a child. The nurse is collecting which of the following types of data from the clients account? a. Historical b. Secondary c. Subjective d. Objective

a. Historical

A nurse is meeting with a new client at a substance use disorder clinic. The nurse and the client are discussing the clients care plan, including medication, follow up appointment, scheduling, and referral to support groups. The nurse is completing which of the following phases of the nursing process? a. Planning b. Implementation c. Evaluation d. Analysis/diagnosis

a. Planning

A nurse is providing education to a group of clients about addiction. The nurse should include which of the following as a definition of addiction? a. Recurring, uncontrollable urges to engage in compulsive behaviors such as substance use in spite of negative consequences b. Needing more and more of a substance to get the level of high or enjoyment as earlier use c. Physiological manifestations that happen when drug or alcohol use is stopped d. Wanting to cut down or stop using drugs and/or alcohol but not being able to

a. Recurring, uncontrollable urges to engage in compulsive behaviors such as substance use in spite of negative consequences

A nurse has successfully completed a drug treatment program and is returning to work three months later with restrictions on their nursing license. Which of the following restrictions might the nurse have for practicing nursing after treatment for drug addiction? a. The nurse can care for clients but cannot administer narcotics b. The nurse can do paperwork on the unit but not care for clients c. The nurse can work as a client care assistant but not an RN d. The nurse can care for clients but no administer any type of medications

a. The nurse can care for clients but cannot administer narcotics

A nurse is caring for a client who is experiencing delirium. Which of the following manifestations should the nurse expect? a. hallucinations b. agnosia c. amnesia d. confabulation

answer: a rationale: The nurse should expect a client who is experiencing delirium to experience hallucinations. Hallucinations are a false sensory belief and they can be visual, auditory, and tactile. Other manifestations can include confusion, hyperactivity, irritability, sweating, tremors, tachycardia, impaired level of consciousness, and seizures.

A nurse is caring for a client who has been diagnosed with ' mad cow disease.' The nurse should identify that the client has which of the following types of dementia? a. CJD b. Huntingdon's disease c. Parkinson's disease d. HIV infection

answer: a rationale: The nurse should identify that the client has prion disease dementia or CJD, also known as "mad cow disease." This disease is transmitted from animal to human from a prion typically found in contaminated beef that is consumed by the client.

A nurse is caring for a client who has huntingdon's disease dementia. Which of the following manifestations should the nurse expect? a. impulsive behaviors b. apathy c. shuffling gait d. depressed mood

answer: a rationale: The nurse should expect a client who has Huntington's disease dementia to exhibit impulsive behaviors. Other manifestations can include dysarthria, impaired gait, and irritability.

A nurse working in an urgent care clinic is obtaining a history from a client who is experience delirium. Which of the following should the nurse identify as a cause of this disorder? a. vitamin deficiencies b. advanced age c. alzheimer's disease d. overhydration

answer: a rationale: The nurse should identify a vitamin deficiency such as B12 can cause delirium. Other causes of delirium can include thyroid disorder, head trauma, physical stressors, along with adverse effects of antidepressants and antipsychotic medications.

A charge nurse is teaching a newly licensed nurse about the use of music therapy for clients who have alzheimer;s disease. Which od the following information should the nurse identify as the prupose of music therapy? a. calms the brain b. evokes memories c. decreases depression d. loosens amyloid plaques in the brain/

answer: b rationale: The charge nurse should include in the teaching that music therapy evokes memories for clients who have Alzheimer's disease.

A nurse is caring for a client who has alzheimer's disease and requires assistance with bathing and getting dressed in the morning. The nurse should identify that the client is in which of the following stages of the disease? a. mild b. moderate c. severe d. terminal

answer: b rationale: The nurse should identify that a client who has Alzheimer's disease and requires assistance with bathing and getting dressed in the morning is in the moderate stage of the disease. In the mild stage, the client who has Alzheimer's disease requires assistance with planning and organizing. In the severe stage, the speech of a client who has Alzheimer's disease degrades to a few words and requires total care. In the terminal stage, the client who has Alzheimer's disease is not able to sit up or hold their head up. The client is immobile and may lie in the fetal position while in bed.

A nurse is providing teaching to a client who has been newly diagnosed with huntington's disease dementia. Which of the following information should the nurse include in the teaching? a. this condition is a result of your previous brain injury b. severe motor funtion loss occurs within five years c. you will experience involuntary jerking motions d. you contracted this condition from consuming contaminated beef

answer: c rationale: The nurse should include in the teaching that clients who have Huntington's disease dementia can experience involuntary jerking motions also known as chorea.

A nurse is caring for a client who has dementia. The client had a CT scan of the head that indicates amyloid plaques. The nurse should identify that the client has which of the following types of dementia? a. prion disease b. traumatic brain injury c. alzheimer's disease d. frontotemporal lobar degeneration

answer: c. rationale: The nurse should recognize that a CT scan of the head that indicates amyloid plagues is a finding in clients who have Alzheimer's disease.

A nurse is caring for an older adult client who has dementia. Which of the following findings should the nurse expect? a. unable to remember the name of a local restaurant b. misplacing keys c. forgetting appointment date d. inability to manage finances

answer: d rationale: The nurse should expect a client who has dementia to be unable to perform calculations such as managing their finances. Clients who have dementia might also exhibit poor judgment and attention span, along with impaired memory and abstract thinking.

A nurse is caring for a client and the provider suspects the client might have frontotemporal lobar degeneration dementia. Which of the following tests should the nurse anticipate the provider to prescribe to confirm this diagnosis? a. biopsy b. ECG c. Positron emission tomography d. computed tomography

answer: d rationale: The nurse should identify that a computed tomography (CT) scan can detect atrophy of the brain, which can indicate frontotemporal lobar degeneration dementia.

a nurse is speaking with the caregiver of a client who has dementia about including omega-3 fatty acids in the client's diet. Which of the following foods should the nurse recommend? a. fruits with seeds b. chicken c. red meat d. leafy vegetables

answer: d rationale: The nurse should recommend the client consume green leafy vegetables. Green leafy vegetables are high in omega-3 fatty acids, which promote cognitive function for clients who have dementia. Other foods high in omega-3 fatty acids are fish and nuts.

A nurse is reviewing the medical records of a group of clients. Which of the following clients should the nurse identify as at risk for developing delirium? a. a 25 year old client who has alcohol use disorder b. a 20 year old client who consumed excessive amounts of alcohol c. a 14 year old adolescent who has received an immunization d. an 85 year old client who has a urinary tract infection

answer: d rationale: The nurse should identify a client who is 85 years of age and who has a urinary tract infection is at risk for developing delirium. An infection, electrolyte imbalance, or dehydration can cause delirium in an older adult client.

A nurse is planning a music therapy activity for a group of clients who have dementia. Which of the following should the nurse identify as the purpose for this activity? a. improve social skills b. increase physical activity c. improve speech d. improve appetite

answer: d rationale: the nurse should identify that music therapy is effective in improving appetite as well as decreasing depression in clients who have dementia.

A nurse is caring for a newly admitted client who has experienced a traumatic event. Which of the following 2 client findings require the nurse to immediately follow-up? a. Client's reluctance to speak to friends b. Client's statement regarding harming others c. Lack of physical injury to the client d. Client's statement regarding feelings when awakening e. Client's inability to relax

b, d

A nurse is developing education for a parenting class about adverse childhood events (ACEs). Which of the following statements should the nurse include in the education? a. "Prior to age 1, children have natural protection from stressors and are unlikely to experience physiological changes from stress." b. "Children who are exposed to repeated adverse childhood events are at an increased risk for developing physical and mental health issues." c. "Experiences of trauma or adverse childhood events result in permanent changes to the brain that cannot be altered." d. "Children's brains are fully developed by the age of 10, and this provides psychological protection from ACEs that occur prior to that age."

b. "Children who are exposed to repeated adverse childhood events are at an increased risk for developing physical and mental health issues."

A nurse is caring for a client in a substance use disorder clinic. The client was referred by their healthcare provider, who is concerned that they might have a problem with misusing prescription pain medication. Although the client has kept this appointment, they insist there is nothing wrong with them, and that they do not have a problem with their pills. Which statement by the client may indicate a substance use disorder. a. "I have been prescribed pain medication for 3 years because of a back injury." b. "My provider is just mad that I have missed three appointments with them and haven't gotten my annual screening this year." c. "I try to get out and take walks when the pain lets up." d. "I am planning on moving in with my sister so she can help me."

b. "My provider is just mad that I have missed three appointments with them and haven't gotten my annual screening this year."

A nurse is developing a discharge plan for a client who is in substance use rehabilitation. The nurse should include which of the following treatment modalities to decrease the likelihood of relapse? a. Physical therapy, occupational therapy, pet therapy b. 12-step programs, cognitive-behavioral therapy, support groups c. Intensive, long-term residential treatment d. Art therapy, music therapy, yoga

b. 12-step programs, cognitive-behavioral therapy, support groups

Which of the following is a guiding principles for nurses when providing care to a client who have a substance use disorder? a. Addiction is a choice, clients need to realize it is their fault b. Addiction is a complex brain disorder, healthcare providers, need to treat their clients who have addictions with empathy and compassion c. The underlying etiology of addiction in unknown d. Addiction is caused by cognitive deficits in the brain, which results in the client's inability to change

b. Addiction is a complex brain disorder, healthcare providers, need to treat their clients who have addictions with empathy and compassion

A nurse is providing education to a group of clients about neurotransmitters. Which of the following neurotransmitters should the nurse include that is implicated in the reward pathway of the brain and addiction? a. Serotonin b. Dopamine c. Norepinephrine d. Y-aminobutyric acid

b. Dopamine

A nurse is meeting with an established client at a substance use disorder clinic. The client has been in treatment for six months. In this meeting, the client shares with the nurse that their partner previously would bail them out of jail when they were arrested for DUI. The client says their partner would also call into the workplace and tell the supervisor that the client was too ill to come to work when they were hung over from drugs or alcohol. The partner's behavior is indicative of which of the following? a. Codependency b. Enabling c. Intervention d. Passive-aggressiveness

b. Enabling

A nurse is caring for a client whose alcohol use is determined to be heavy. The nurse should identify that the client is at risk of developing which of the following conditions? a. Bipolar disorder, schizophrenia, PTSD b. Hepatitis, pancreatitis, cirrhosis of the liver c. Parkinson's disease, tardive dyskinesia, brain swelling d. Lupus and other autoimmune disorders

b. Hepatitis, pancreatitis, cirrhosis of the liver

Which of the following factors is identified as a risk factor for developing addictions? a. High school performance b. Peer pressure c. Higher socio-economic status d. Independent nature

b. Peer pressure

A nurse is providing parenting education to a group of new parents at the area community center. Which of the following types of trauma prevention is the nurse providing? a. Secondary prevention b. Primary prevention c. Primordial prevention d. Tertiary prevention

b. Primary prevention

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears that the client may go into withdrawal and require medical supervision. The clients manifestations now include anxiety, tremors, BP 166/100 mm Hg, and tachypnea. The nurse should recognize that the client is experiencing which of the following stages of withdrawal from alcohol? a. Stage 1 (mild) b. Stage 2 (moderate) c. Stage 0 (pre-withdrawal) d. Stage 3 (severe)

b. Stage 2 (moderate)

A nurse is caring for a young adult client who experienced a traumatic event and appears to be hallucinating. The client has no history of or evidence of risk factors for schizophrenia spectrum disorders and the client's toxicology screen is negative. Which of the following diagnoses provides the best explanation of this client's clinical manifestations?

brief psychotic disorder

A nurse overhears a coworker say, "I get that some people have a hard childhood, but eventually they need to get over it." Which of the following responses should the nurse make? a. "People who hav experienced adverse childhood events are only found in vulnerable populations." b. "It is completely genetics and biology; some people are just unable to get over their past and move on." c. "People who experience adverse childhood events are changed biologically and genetically" d. "It is only people who experience trauma later in life who will really struggle."

c. "People who experience adverse childhood events are changed biologically and genetically"

A nurse is providing care to a 4-year-old client who has been recently diagnosed with reactive attachment disorder. Which of the following statements by the nurse accurately describes this disorder? a. "The child developed reactive attachment disorder because they were bitten by a dog 2 weeks ago." b. "This child displays inappropriate attachment and is overly familiar with a stranger." c. "Reactive attachment disorder can occur when there is an absence of adequate caregiving, including the child going many hours without being held or touched as an infant." d. "The child has recurring nightmares and often displays outbursts of anger even when they are not provoked by others."

c. "Reactive attachment disorder can occur when there is an absence of adequate caregiving, including the child going many hours without being held or touched as an infant."

A nurse has attended an in-service regarding nursing care for clients who have experienced trauma. Which of the following statements by the nurse represent an understanding of trauma? a. "Trauma is usually a series of events rather than a one-time occurrence." b. "Trauma is a specific term used to describe visible wounds that a client has experienced." c. "Trauma is a broad term that refers to a person's physical, psychological, or emotional response to an adverse event." d. "Trauma is predominantly experienced in adulthood as children cannot recognize trauma."

c. "Trauma is a broad term that refers to a person's physical, psychological, or emotional response to an adverse event."

A nurse is meeting with a new client at a substance use disorder clinic. The client should take which of the following actions during the assessment phase of the nursing process? a. Formulate a diagnosis based in the information gathered b. Plan interventions based on the information gathered and the diagnosis c. Ask the client for information regarding their current problem, identify signs and symptoms, and use screening tools as appropriate d. Evaluate whether the plan of care has been effective

c. Ask the client for information regarding their current problem, identify signs and symptoms, and use screening tools as appropriate

A nurse has been confronted about stealing and taking drugs from the narcotics cart in the medication room. Which of the following is the most serious consequence of the nurse being impaired while caring for clients? a. Coworkers will notice the nurse's impairment and not want to work with them b. The nurse may fall asleep on their shift c. Clients could be harmed or die d. Clients may notice the nurse's impairment and sue the hospital

c. Clients could be harmed or die

A nurse is providing substance use education to a group of parents. The nurse should include which of the following factors that contribute to teenagers being at risk for substance use disorder? a. Although teenagers have fully developed brains, they are more susceptible to peer pressure b. Teenagers have more underlying psychiatric issues than adults, making them more susceptible to addiction c. Decision-making, judgment, and self-control are not fully mature in teenagers

c. Decision-making, judgment, and self-control are not fully mature in teenagers

A nurse is working with the provider to determine which laboratory test should be ordered for a client who is suspected of chronic alcohol use. The nurse should identify that which of the following sets of laboratory data might indicate chronic alcohol use? a. BNP, cardiac enzymes, alkaline phosphatase b. CBC, WBC, neutrophils, platelets c. Liver panel, compressive metabolic panel, BAL/BAC, magnesium d. Blood glucose level, T3, T4, TSH

c. Liver panel, compressive metabolic panel, BAL/BAC, magnesium

A nurse manager is reviewing reports of a staff nurse. The reports indicate that the staff nurse has had an increase in being late and calling out sick more often. The staff nurse has been experiencing mood swings that have made it difficult for other nurses to work with them. Which of the following could also indicate that the staff nurse might be using substances? a. Volunteering to serve on the crisis and disaster preparedness team as the triage and medication nurse b. Volunteering to serve on the pharmacy error prevention commitee c. Volunteering to give all the narcotics doses to clients for the shift d. Volunteering to reorganize the nursing station and medication room

c. Volunteering to give all the narcotics doses to clients for the shift

A nurse is caring for a client who has depression, diabetic polyneuropathy, and significant neuropathic pain. The nurse hears a PA say "they are admitted frequently and always report being in pain. I think they are a drug seeker" which of the following responses should the nurse make? a. "You certainly call things like you see them. I am going to ignore you said that!" b. "Yes, this client is always in pain. You should remember that it is our job to take care of people like them." c. "What is bothering you? Just keep your comments and opinions to yourself." d. "It is not appropriate to stereotype clients. It seems like you may have bias which could affect client care."

d. "It is not appropriate to stereotype clients. It seems like you may have bias which could affect client care."

A nurse has attended an in-service education regarding trauma-informed care approach. Which of the following statements by the nurse reflects an accurate description for the goal of trauma-informed approach? a. "A trauma-informed approach to care is a process of steps which evaluates injury to determine priority of care." b. "Nurses should focus on immediate client care rather than the trauma that has happened to the client." c. "Trauma-informed care is most important in the emergency department and with first responders. They see the most trauma." d. "Nurses should understand the effects of trauma and structure client care to promote positive outcomes."

d. "Nurses should understand the effects of trauma and structure client care to promote positive outcomes."

A nurse is analyzing assessment data for a group of clients. Which of the following clients is at greatest risk of developing PTSD? a. A 23-year-old client who has a tibial fracture following a motor vehicle accident b. A 72-year-old client who lost their partner to metastatic breast cancer c. A 29-year-old client who has Type 1 diabetes mellitus and is postoperative following an appendectomy d. A 36-year-old client who has a maxillofacial fracture caused by their partner

d. A 36-year-old client who has a maxillofacial fracture caused by their partner

A nurse is teaching parents of adolescence about substance use disorder. Which of the following information should the nurse include? a. Relapse is uncommon in adolescents who achieve sobriety during their first treatment b. The effect of substance use or abuse causes a decrease in dopamine levels c. The potential to become addicted to a drug is magnified if it is taken orally d. Changes in mood, decline in performance at school and work, and changes in peer group are warning signs of substance use disorder

d. Changes in mood, decline in performance at school and work, and changes in peer group are warning signs of substance use disorder

A nurse is caring for a 78-year-old client who is being seen for hypertension. The client has type two diabetes, mellitus with neuropathy and high cholesterol. At their routine providers visit, the client reports to the intake nurse that they have been drinking alcohol more heavily lately ever since their partner passed away. One of their friends told them they should cut down on the alcohol use. What are risk factors for alcohol or substance use in older adult population? a. Belonging to community clubs or other social groups where drinking and drug use occurs b. Female gender, high socio-economic status, college graduate c. Experiencing emotional instability such as anger issues and mood fluctuations d. Chronic medical conditions, pain, emotional losses, male gender

d. Chronic medical conditions, pain, emotional losses, male gender

A nurse is reviewing a clients risk for substance use disorder. Which of the following information about ingestion routes accurately describes substance addiction potential? a. Some routes of substance use give the addict slower, more drawn out pleasure from the drug b. Taking pills orally increases risk for addiction because pills are easy to access and use c. The route does not make a difference, but the specific drug consumed is the factor d. Smoking or injecting a substance increases the potential for addiction

d. Smoking or injecting a substance increases the potential for addiction

A nurse is caring for a client who was diagnosed with adjustment disorder after losing their job 2 months ago. For which of the following manifestations should the nurse monitor the client? a. Persistent avoidance b. Psychosis c. Dissociative amnesia d. Suicidal ideation

d. Suicidal ideation

Which of the following are specific risk factors for healthcare professionals, to become addicted to alcohol or drugs? a. Mandatory continuing education, license renewal, financial issues b. Higher divorce rate, legal problems, disciplinary actions at work c. Higher incidence of risk-taking behaviors, reckless health practices, work parties with alcohol and drugs present d. Work stress and burnout, work injuries, access to drugs

d. Work stress and burnout, work injuries, access to drugs

A nurse is caring for a client who has been diagnosed with schizophrenia. Which of the following should the nurse identify as a positive symptom?

hallucination

A nurse is caring for a client who has a major depressive disorder. Which of the following findings should indicate to the nurse the client is experiencing psychosis?

hallucinations

A nurse is speaking with a client about the potential impact of living with a serious mental illness. Which of the following pieces of information should the nurse share?

having a job is positively associated with recovery from serious mental illness (SMI)

A nurse is providing education to a group of staff members about risk factors for schizophrenia. Which of the following risk factors should the nurse include?

having a twin sibling who has the disorder

A nurse is caring for a client who is experiencing psychosis. Which of the following manifestations should the nurse identify as a positive symptom of schizophrenia?

hearing voices

A nurse is caring for a client who has a SMI and has been recently released from prison. Which of the following factors related to being released from a prison increases the client's risk of relapsing?

inability to find housing

A nurse is caring for a client in a Veterans' Administration facility. The nurse should first address the client's XXX due to XXX

living situation; physiological needs

A nurse is caring for a client who has schizophrenia. The client states, "My health care provider indicated that I likely got schizophrenia due to complications experienced in utero." Which of the following risk factors is this complications linked to?

physiological

A nurse is instructing a client who is experiencing hallucinations about medication use. Which of the following statements should the nurse make?

"Both prescription and over-the-counter medications can sometimes cause hallucinations in some people."

A nurse is caring for a client who has been diagnosed with schizophrenia. The client is exhibiting delusional behavior stating that a new nurse is from the FBI and is stealing their thoughts and ideas. Which of the following statements should the nurse make?

"I can see you are very concerned. The new nurse is not from the FBI and will not harm you."

A nurse is providing information about hallucinations to a client who has schizophrenia. Which of the following statements should the nurse make?

"It is when you see or hear things that others are not experiencing."

A nurse is talking with the family of a 28 year old client who has been diagnosed with schizophrenia. The client's parents ask, "Will my child ever be able to have a good quality of life?" Which of the following responses should the nurse make?

"With treatment and support your child will be able to live a productive and rewarding life."

A nurse is admitting a client who is somatic symptom disorder and reports recurrent episodes of back pain. Which of the following action should the nurse take first?

Build a therapeutic relationship with the client

A nurse is discussing personality disorders with a group of newly licensed nurses. The nurse includes that the Diagnostic and Statistical Manual of Mental Disorders, FIfth Edition (DSM-5) identifies hwo many personality disorders?

10 The DSM-5 identifies 10 personality disorders divided into 3 clusters.

A nurse is reveiwing Erikson's Eight Stages of Development. During which of the following age ranges does the client experience the identity vs role confusion stage?

12 to 18 years According to Erikson's Eight Stages of Development, the identity vs. role confusion stage occurs between 12 to 18 years of age.

A nurse is preparing to provide a presentation about somatic symptom disorder and related disorders at a local high school. Which of the following would be correct about the prevalence of somatic symptom disorder, and the general population?

4 to 6%

Assessment findings for seven-year-old child. ADHD versus Tourette's syndrome.

ADHD • short, attention span • inability to follow directions • Difficulty completing tasks Tourette's syndrome • motor tics • Vocal tics

A nurse is caring for a client who has a cluster C personality disorder and is helping the client explore ways to cope with anxiety. Which of the following actions should the nruse tell the client has been shown to decrease anxiety?

Adopting a pet Pet therapy has been shown to decrease anxiety in clients who have anxiety disorders.

A nurse is providing care to a client who has down syndrome. The nurse recognizes the client is at increased risk for developing which of the following conditions.

Alzheimer's disease

A nurse is providing teaching to the caregiver of a client who is in the moderate stage of Alzheimer's disease. which of the following client findings should the nurse inform the caregiver to expect at this stage? a. forgetting the day of the week b. problems communicating c. difficulty getting dressed d. leaving the stove turned on

Answer: c rationale: The nurse should include in the teaching that a client who is in the moderate stage of Alzheimer's disease can experience difficulty getting dressed and may require assistance. Other manifestations during this stage can include a tendency to wander, having trouble recalling information, moodiness, confusion regarding location and time, along with behavioral changes. Forgetting the day of the week is an expected finding that occurs due to age related cognitive decline. Problems communicating occurs in the severe stage of Alzheimer's disease. Leaving the stove turned on occurs during the severe stage of Alzheimer's disease.

A nurse in an emergency department is caring for a client and finds a razor blade hidden in the client's personal belongings. The nurse should identify that this finding is consistent with which of the following disorders?

Borderline personality disorder The nurse should identify that one of the characteristics of borderline personality disorder is self-harm, so a client who has this disorder might try to smuggle in sharp objects to engage in cutting.

A nurse is caring for a client who has borderline personality disorder. The nurse should identify that which of the following factors may have contributed to the development of this diosrder?

Childhood rejection The nurse should identify that exposure to traumatic events during childhood, such as fear of rejection and/or abandonment, are contributing factors for the development of borderline personality disorder.

A nurse on a mental health unit is teaching a newly licensed nurse about psychotic features among clients. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

Clients who have borderlien personality disorder can exhibit psychotic features. The nurse should identify that clients with borderline personality disorder can exhibit psychotic features because of the intensity of their cognitive distortions.

A nurse is talking to a parent of a pediatric client recently diagnosed with autism spectrum disorder. The parent of the client states "I'm at a loss of what to do. I don't even know where to begin in caring for my own child" which of the following actions would support the best outcomes for a parent caring for a child who has ASD?

Connect the family with a local autism support group

Which of the following activities would be impacted for a client who has ADHD?

Cooking due to the variety and sequence of tasks

A nurse is teaching a group of newly licensed nurse is about the ideology of autism spectrum disorder which of the following factors should the nurse include in the teaching?

De Novo genetic mutation A genetic alteration that is present for the first time in one family member, rather than an inherited gene my account for ASD when there's no indication of a family history of the condition

1100:Interview with family member:Family member accompanied a 20-year-old client due to concern over client's increasingly unusual behaviors. The client works for a package delivery company. During a recent delivery, the client handed a package to a person standing outside the door of a building and shouted, "Bam! A gift for you!"The client has been checking every delivery address numerous times because they occasionally hear voices saying that they "missed a delivery." The family member is also

Determine if the client is experiencing command hallucinations. Teach the client how to use coping skills to reduce stress. Encourage the client to attend psychotherapy. Administer an antipsychotic medication to the client.

A charge nruse is reveiwing a diagnostic criteria for several personality disorders with a group of newly licensed nurses. Which of the following reference publications will be most helpful?

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) MY ANSWER The DSM-5 is a comprehensive collection of classifications of mental disorders and includes the criteria used by healthcare providers to determine specific diagnoses.

A nurse is assessing an adult client who has dyslexia. Which of the following findings should the nurse expect to observe?

Difficulty reading at the expected level

Which of the following findings might be present in a child who has an intellectual disability?

Difficulty with problem-solving Intellectual disabilities, include problems with reasoning, problem-solving, planning, abstract, thinking, judgment, academic learning, and learning from experience

Which of the following is a cognitive sign of a learning disability in a child?

Difficulty with reading or memory recall

A nurse is planning care for a client who has a communication disorder. Which of the following action should the nurse plan to take?

Explore alternative methods of communication

A nurse on a mental health unit is caring for a client who states that the food is poisoned. Which of the following actions should the nurse take?

Give the client food that is in pre-sealed containers. The nurse should identify that this will build trust with the client, who is concerned about their safety, until they can decrease their anxiety.

A nurse is conducting a gropu discussion regarding how personal biases can affect the care provided to clients who have mental health disorders. The nurse should identify that which of the following instruments is available to use as a self assessment tool to determine bias?

Harvard Implicit Association Test The Harvard Implicit Association Test is a self-administered test to determine implicit biases.

A nurse is preparing a presentation on nursing theorists for a unit meeting. Which of the following theorists should the nurse include as the person who developed teh theory of interpersonal relations?

Hildegard Peplau Hildegard Peplau developed the theory of interpersonal relations.

Which of the following outcomes should a school nurse expect after implementing an early screening program for ADHD

Improving the likelihood of successful treatment

A nurse is caring for a six-year-old child who has attention deficit hyperactive disorder, which of the following action should the nurse take?

Initiate cognitive behavioral therapy

A nurse is discharging a client w ho has a personality disorder. Which of the follwoing actions should the nurse take?

Involve the client in planning which resources will be needed after discharge. When clients participate in creating their discharge plan they are more likely to comply with the plan.

A nurse has recommended an assessment for autism spectrum disorder to a patient and the parent has declined. Which of the following barriers to treatment is present?

Lack of parental consent

Which of the following behaviors is commonly associated with clients who have autism spectrum disorder?

Lines up the toys in their bedroom Children with ASD, my participate in repetitive and restrictive activities

0900:Client brought to the emergency department via EMS after their partner called emergency services due to client threating to shoot themself. Partner reports client owns several guns that are kept in the home.Partner reports the client was recently passed over for a significant promotion at work. The partner states the client "has always been really entitled and thinks they're better than everyone else." Being rejected for the promotion caused the client to start missing work and drinking lar

Maintain constant observation of the client Role model empathy with the client Avoid becoming defensive in response to the client Refer the client to a psychotherapist While the nurse should plan to alternate caregivers for clients who engage in splitting behaviors, this is not a behavior exhibited by clients who have narcissistic personality disorder.

A nurse is caring for a 10 year old child. Which of the following statements by the child's guardian suggest a risk factor for Tourette's syndrome?

My father has a tic disorder

Which of the following environmental factors has been linked to an increased risk for the development of developmental coordination disorder DCD?

Parental alcohol exposure These children will have experienced a low birthweight, premature birth, family, history, and prenatal exposure to alcohol or drugs

1000: Group therapy sessionClient #1 verbalizes severe mistrust of staff. Client also reports malevolent actions of family members and that the family has held a grudge over one of the client's siblings for the past two years.Client #2 did not participate in group. Client appeared indifferent to criticisms or praises of others and appears to not be affected by other clients' statements made to or about them.Client #3 appears uncomfortable in the group setting. Client's contributions to the discu

Suspicousness: Schizotypal and paranoid disorder Depersonalization: Schizoid Social withdral: Schizoid disorder Blame others for their soicial isolation: Schizotypal Unwllingess to forgive: Paranoid personality disorder

Which of the following observations of a client who has ADHD demonstrates behavioral pattern of hyperactivity?

Tapping hands or feet

A nruse is educating newly licensed nurses about the diathesis stress model impact on client care. The nurse stresses that which of the follwoing interacts with enviornmental triggers and influences teh client's response to stressors?

Temperament The diathesis-stress model states that the client's temperament and the environment work together to influence the client's response to stressors.

A nurse is providing an in-service training to a group of newly licensed nurse is about their function as part of the interdisciplinary team providing care to clients who have neurodevelopmental disorders. Which of the following statements should the nurse include in the presentation?

The presence of comorbidities in many clients, who have neurodevelopmental disorders, requires working with various providers in order to deliver effective services

A nurse is caring for a client who has schizophrenia. Which of the following should the nurse identify as a social determinant of health for the client?

access to healthy food

A nurse is caring for a client who has schizophrenia and is unaware of their own mental health. Which of the following is the client experiencing?

anasognosia

A nurse is caring for a client who is confused and unable to remember the time of year. The provider suspects the client has dementia. Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition? a. MRI Scan b. Uric acid test c. Platelet count d. ECG

answer: a rationale: The nurse should anticipate the provider to prescribe an MRI of the client's head to diagnose dementia.

A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect? a. shuffling gait b. sundowning c. rapid eye movement during sleep d. tremors

answer: d Rationale: The nurse should expect a client who has delirium to exhibit manifestations of tremors, tachycardia, confusion, sweating, hyperactivity, and hallucinations. Shuffling gait is a manifestation of Lewy body disease and Parkinson disease dementia. Sundowning is a manifestation of Alzheimer's disease Rapid eye movement during sleep is a manifestation of Lewy body disease and Parkinson's disease dementia.

A nurse is reviewing assessment findings for a 22 year old client who was found wandering in the street. Which of the following manifestations suggests the client is experiencing positive symptoms of psychosis?

clanging speech

A nurse is caring for a client who is being evaluated for schizophrenia spectrum disorder. Which of the following is used to determine a diagnosis for schizophrenia?

clinical observation

A nurse is caring for a client who has been diagnosed with schizophrenia. Which of the following findings indicates that they client is in the residual phase of the disorder?

decline in symptoms of psychosis

A nurse is caring for a client who has schizophrenia. Which of the following describes the physiological changes caused by exposure to risk factors for this disorder?

decreased grey matter volume in the brain

A nurse is caring for a client who is experiencing psychosis and states that they are the president of the US. The nurse should identify that they client is experiencing which of the following?

delusions

A nurse is working in a community health center is providing an in-service to a group of residents about schizophrenia. Which of the following should the nurse include as an environmental risk factor for this condition?

experiencing poverty

A client who has schizophrenia shares with their nurse that they are feeling lonely and isolated. Which of the following actions is the nurse's priority?

share information about support groups for people who have serious mental illness (SMI).

A nurse is caring for a client with schizophrenia. Select the 3 findings that require immediate follow up by the nurse

temperature, stupor-like state, and muscle rigidity

A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse identify as a cognitive symptom?

unable to concentrate

A nurse is caring for a client who is at risk for developing schizophrenia. Which of the following findings should the nurse identify as an environmental risk factor?

using cannabis

A nurse is providing discharge instructions for a client who is prescribed clozapine. Which of the following information should the nurse include?

weekly blood draws will need to be done while taking this medication

While assessing a toddler for Nurodevelopmental disorders, select three findings that require immediate follow up

• rocking back-and-for • language skills • lack of eye contact

A nurse is planning care for a client who are somatic symptom disorder. Which of the following action should the nurse include?

• teach the use of relaxation techniques • provide symptomatic relief measures as prescribed • provide education on basic cognitive behavioral and mindfulness interventions