Mental Health Chapter 10
The nurse is preparing a teaching plan for a client who is going to be discharged with a prescription for lithium. What will the nurse teach the client to watch for regarding the signs and symptoms of severe lithium toxicity?
Confusion, ataxia, muscle weakness
The nurse is conducting an intake interview with a young man diagnosed with generalized anxiety disorder. What type of behavior would the nurse expect to observe?
Is unable to concentrate and is irritable when questioned
Which problem might the nurse observe in a client who has undergone a full course of electroconvulsive therapy (ECT)?
Memory loss
The nurse is conducting an admission assessment interview with an adult Native-American client. Which therapeutic approach would be most effective?
Use a soft voice with open ended statements and reflective technique; avoid direct constant eye contact.
The nurse manager is planning staffing assignments for a psychiatric unit with numerous clients who have the diagnosis of schizophrenia. The nurse would:
Use the same staff members as often as possible because of their experience in caring for clients with schizophrenia.
The mother of a 15-month-old child who is immunosuppressed asks about continuation of the childhood vaccines. Which immunizations are not recommended to be given to the child during immunosuppression?
Varicella; measles, mumps, and rubella (MMR)
A client receiving phenelzine sulfate (Nardil) must be taught to avoid which of the following foods?
Aged cheeses, beer, and avocados
When caring for a client admitted for medically monitored detoxification from alcohol, the nurse would assess for which of the following signs and symptoms of withdrawal?
Anorexia, irritability, nausea, and tremulousness
Which of the following would be noted as an adverse effect in a client receiving lithium carbonate (Eskalith)?
Fine hand tremors
The nurse is reviewing with a client, who is positive for human immunodeficiency virus, important implications of his antiretroviral therapy. In reviewing the medications the client currently takes, which one would cause the nurse the most concern?
St. John's wort
Which of the following best describes binge eating?
The client has been rapidly consuming a large amount of food.
A client has cognitive impairment. Which functional problems is this client most likely to exhibit? Select all that apply.
1,2,3
The nurse is assessing a client using the Mini-Mental State Exam (MMSE). What sample questions would be typically part of the examination? Select all that apply.
1,2,4,6
The nurse is preparing discharge teaching for a woman newly diagnosed with SLE. What will be important for the nurse to include in the teaching plan? Select all that apply.
1,3,5,6
A client has systemic lupus erythematosus (SLE). What statement best describes this client's immune response?
An immune response that no longer recognizes normal body tissue
What is an allergic reaction that can quickly deteriorate into shock and death?
Anaphylaxis
During an intake interview on a psychiatric unit, the client makes numerous positive comments about her deceased husband, saying he was perfect. She sometimes speaks of him as if he were still alive. She told the nurse she has been depressed on and off since her husband's death 3 years ago. What is the client's behavior suggestive of?
Experiencing a prolonged grief reaction
A nurse in a psychiatric unit observes a client kicking the furniture and walls while yelling that no one visits her. What would be the priority nursing intervention?
Firmly tell the client in a calm and clear tone of voice to stop kicking the furniture.
A nurse at the children's immunization clinic is doing a head-to-toe assessment on a child. The nurse notices streak marks that are raised and red and areas of broken skin. The mother states that child ran through a rose bush, where she received the scratches. The priority response would be for the nurse to:
Immediately report the suspected abuse to the appropriate authorities.
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis jirovecii pneumonia (PJP, PCP). Which nursing problem has the highest priority for this client?
Impaired oxygenation
A client was admitted to the hospital and tells the nurse that she has had a problem with drinking for several years. About 8 hours after admission, the client begins to experience alcohol withdrawal symptoms. The nurse would identify what symptom as characteristic of this phase?
Increased irritability and tremulousness
A client taking lithium (Eskalith) would most likely experience which of the following signs and symptoms?
Increased thirst, increased urination
To evaluate the progress of the client's systemic lupus erythematosus (SLE), the nurse evaluates which data?
Increasing levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
The nurse is reviewing with a certified nursing assistant (CNA) the care for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS) and has developed P. jiroveci pneumonia (PJP, PCP). Which of the following precautions would the nurse review with the CNA?
Standard precautions
The nurse is caring for a client who has an eating disorder. Which nursing intervention(s) would be appropriate for this client?
Weigh the client once a week and contract for the amount of food to be eaten.
The nurse is conducting client teaching on the topic of seizures and cocaine use. Which of the statements made by the client demonstrates knowledge of cocaine-related seizures?
"Any type of cocaine use can produce a seizure in any person."
An older adult, who is a widower, is hospitalized after complaining of difficulty sleeping, extreme anxiety, shortness of breath, and feelings of dismay. What is the best response for the nurse to make?
"Can you talk about what might have happened recently that may have triggered these feelings?"
A client tells the nurse that a voice keeps telling him to bark like a dog when others ask him a question. Which response by the nurse is the most appropriate for the client?
"Even though I don't hear the voices, I understand that you do."
A 32-year-old woman with systemic lupus erythematosus (SLE) is being treated with azathioprine (Imuran). Which of the following comments by the client would cause the nurse the most concern?
"I am going to stop my birth control pills; I am concerned about the side effects."
A geriatric client is confused, and total bed rest has been prescribed. The nurse finds him walking in the hall. What is the best nursing response?
"I know this is confusing. Let me help you back to bed."
A client says, "I think everyone is out to get me. I don't trust you at all." The nurse's best response would be:
"I know you think everyone is out to get you, but I don't see it that way."
The nurse notices the client wringing his hands after a visit from his psychiatrist. What is the nurse's best initial response?
"I've noticed that you are wringing your hands.
Which statement by the mother of a child with attention-deficit/hyperactivity disorder (ADHD) indicates that she needs further teaching?
"It is a priority to have my child complete any homework assignments right after school."
While talking with a client about his chemical dependency, the client states, "I wish I would have never used cocaine. It's ruined my life!" What would be the most appropriate response by the nurse?
"It sounds like you've thought a lot about your cocaine use."
An infant is scheduled for a pyloromyotomy. The mother begins to cry and says, "I'm such a bad mother." What is an appropriate response by the nurse?
"Tell me what makes you think you are a bad mother."
A 9-year-old client with leukemia asks, "Will I die?" What is an initial therapeutic response based on the needs of the dying child?
"Tell me what you are thinking about dying."
The nurse is teaching a client about the antidepressant drug fluoxetine (Prozac). Which of the following statements is true concerning this drug? Select all that apply.
1,2,5,6
A client's feelings of despair and depression have lifted, and she tells the nurse, "I feel better now." The nurse understands that this client is:
A client's feelings of despair and depression have lifted, and she tells the nurse, "I feel better now." The nurse understands that this client is:
The nurse is placing a diet order for the client with bipolar disorder (manic phase). Which foods would be most appropriate?
A ham and cheese sandwich, carrot and celery sticks, apple, and cookies
The nurse is following up after therapy plans were discussed by the physician with the client who is considering antiviral therapy for the treatment after confirmation of a positive status for the human immunodeficiency virus (HIV) test. The client asks the nurse how long the therapy will last. The nurse bases a response on the understanding that therapy lasts:
A lifetime
During an interview with a client who has a diagnosis of schizophrenia, the nurse notes that the client says, "My sister fun, car, swing, letter, orange, boat." The nurse's interpretation and diagnosis of this type of response would be to document:
A word salad
A child has chickenpox. What developed in the client's body as a result of this virus?
Antibodies
A nurse is caring for a client who received a penicillin injection about 15 minutes earlier. The client complains of itching around the mouth, and this rapidly progresses to severe dyspnea and respiratory distress. What are the priority nursing actions?
Anticipate need for possibility of endotracheal intubation, begin oxygen, call for assistance, and obtain emergency cart.
The nurse is assisting a client with his antiretroviral therapy. What can the nurse do to help the client take his medications as prescribed?
Assess the client's activities of daily living and his lifestyle routine to determine when he can most easily remember to take his medications.
A family member of a client asks the nurse the purpose of the Mini-Mental State Examination (MMSE). The nurse understands that the MMSE:
Assesses cognitive functioning and the degree of mental impairment
For a terminally ill client to receive quality nursing care, the charge nurse needs to implement which strategy when she assigns staff to care for the client?
Assign the same full-time staff nurses every day.
A nurse is caring for a client with cardiac disease who is beginning to experience denial. What is a primary indicator of denial?
Attempts to minimize the illness
The nurse is caring for a client diagnosed with bulimia and notices Russell's sign. What is Russell's sign?
Bruised knuckles
Which of the following describes how cultural diversity may affect a client's health?
Caucasians and other ethnic groups may self-treat their depression with over-the-counter alternative remedies, such as St. John's wort.
Which of the following defects is most commonly associated with Down syndrome?
Congenital heart disease
What should the nurse do when a client becomes agitated during an admission assessment?
Contact hospital security.
A client in a mental health unit has a persistent idea that he is the son of God. These symptoms indicate he is having what type of delusions?
Delusions of grandeur
A woman is diagnosed with a highly disseminated, metastatic breast cancer. The nurse would expect that her initial reaction at the time the physician gave her the prognosis most likely to be:
Denial
What is an important nursing action to encourage compliance with taking medications for the Alzheimer's client who has a new prescription for donepezil (Aricept)?
Explain to the spouse the schedule and necessary information about administration of the medication.
The nurse is caring for a client who is categorized as HIV-positive, acute infection. What would the nurse anticipate finding on the nursing assessment?
Fatigue, weight loss, night sweats
During a client care conference, a discussion takes place regarding the anxiety of a 9-year-old client with leukemia. In addition to anxiety related to his death, what additional factor might contribute to the child's anxiety?
Fear of separation from his family
A client is discharged with a prescription for lithium carbonate (Lithonate). Discharge teaching includes reporting signs of toxicity, which includes:
Fine tremors and thirst
A client comes to the nurses' station and is upset and verbally abusive when told that her privileges to walk on the grounds have been canceled. What would be the most effective approach by the nurse?
Firmly but calmly escort the client back to her room.
The nurse would identify the occurrence of which situation that would indicate a need for further evaluation because of the client's increased risk for exposure to the human immunodeficiency virus (HIV)?
Frequent sexually transmitted diseases
The nurse is administering medications to a client who has no allergy band on his arm. The nurse tells the client she has his penicillin medication. The client states that the last time he had penicillin, it made his mouth tingle and his hands itch. What would be the best nursing action?
Hold the medication and contact the physician regarding the client's statement about his previous experience with penicillin.
An anxious client is crying and tells the nurse that her husband has recently asked her for a divorce. Which is the best response for the nurse to make?
I can see how upset you are. Let's talk about what happened.
The nurse is developing a teaching plan for the client receiving clozapine (Clozaril). What is important to include in the teaching plan?
Monitor white blood cell (WBC) count and differential weekly for first 6 months, then every 2 weeks.
A child has rubeola. What type of immunity will this child have on his recovery?
Naturally acquired active immunity
A client with Alzheimer's disease is started on a cholinesterase inhibitor. Which side effects are associated with this medication?
Nausea, vomiting, and diarrhea
A recovering cocaine addict reports to the nurse that he is having cravings for the drug. The nurse's rationale for the plan of action is based on the fact that recovering addicts:
Need increased physical activity
A preschooler is found digging up a pet kitten that was recently buried after it died. The best explanation for this behavior is that the preschooler:
Needs reassurance that the kitten has not gone somewhere else
A client has been receiving fluphenazine (Prolixin) for the past 3 weeks. The nurse's assessment notes the following: temperature elevated to 105° F orally, marked muscle rigidity, agitation, and confusion. The nurse recognizes these findings as often associated with:
Neuroleptic malignant syndrome
An appropriate nursing diagnosis for a client who is having difficulty adhering to his plan of care because of ethnic customs is:
Noncompliance related to cultural views
A nurse experiences a needle stick from an IM injection that was just administered to a client who is positive for human immunodeficiency virus (HIV). What would be the best nursing action?
Notify the employee health center and report the circumstances regarding the needle stick.
Which is an appropriate initial nursing measure in caring for a female who has been raped?
Obtain written informed consent for examination.
A client is diagnosed with an immunodeficiency disease. The nurse would understand what is characteristic of this condition?
Occurs when a client's body is unable to defend itself from an invading microorganism
A client in a psychiatric unit is being monitored for schizophrenia. The nurse would assess the client for the presence of what symptoms?
Paranoia, delusions, hallucinations, and diminished self-care
A client who is positive for the human immunodeficiency virus (HIV) has white raised lesions or plaques in his mouth on the inner cheek and tongue. Nystatin (Mycostatin) has been ordered. What will be important to teach the client about this medication?
Perform oral hygiene, then place medication in your mouth, and "swish and swallow."
The nurse is admitting a client diagnosed with schizophrenia. During the admission interview, the client begins screaming at the nurse, "They are coming after me. They think I killed my sister, but I know it was you!" The nurse would determine that the client is experiencing:
Persecutory delusions
When preparing a client for electroconvulsive therapy (ECT), the nurse would include which of the following actions?
Remove dentures and maintain NPO status.
What is the initial nursing care for the depressed client?
Schedule one nurse to consistently interact with the client and focus on establishing rapport.
Which of the following would be the appropriate action for the nurse in caring for a client with dementia who has an order for cloth restraints?
Secure the cloth restraint ties to the bed frame to protect the client from injury.
What would be a safe approach when planning care for a newly admitted Alzheimer's client who has a history of wandering away from home?
Select a room that is close to the nurse's station.
Which findings would typically be noted on an admission assessment for a client experiencing posttraumatic stress disorder (PTSD)?
Sleeping problems and flashbacks
A client is receiving a monoamine oxidase (MAO) inhibitor and should avoid which of the following food
Swiss cheese
A client is receiving methylprednisolone (Medrol) for treatment of an exacerbation of her systemic lupus erythematosus (SLE). While the client is receiving the medication, what would be an important for the nurse to teach the client?
Take the medication with food and monitor your weight.
A new mother tells the clinic nurse that her 6-week-old infant was born positive for human immunodeficiency virus (HIV). She asks the nurse how long her baby has to live. The nurse's response would be based on the knowledge that:
The antibodies present in the baby's blood may reflect the antibodies received from the mother at the time of birth, and further testing is required to validate the presence of HIV.
A parent brings a young child to the ER, stating that the child fell off the porch swing. What nursing assessment finding would cause the nurse to closely evaluate the situation for the possibility of child abuse?
The child has red, blue, and green bruised areas on her trunk.
After a repeat of the antibody test for the human immunodeficiency virus (HIV), a client continues to have a positive test result but is asymptomatic. The nurse understands which of the following about possible transmission of the virus by the client?
The client is infectious for life.
A 2-month-old infant dies of sudden infant death syndrome. The parents are concerned because their other child, a 4-year-old, has showed more outward grief when her dog died than now when her infant brother died. What should the nurse explain to the parents?
The death of the infant may be so painful and threatening that the preschool-age child must deny it for now.
An infant has an acquired active immunity. Which statement best explains this type of immunity?
The infant has received immunizations.
A woman is pregnant and is being seen in the clinic for the first time. She has a history of being HIV positive. What will be important for the nurse to teach this client?
The woman should continue antiretroviral prophylaxis throughout pregnancy and will be scheduled for a cesarean delivery to reduce the risk of mother-to-child transmission of HIV.
A client with a diagnosis of AIDS has developed P. jiroveci pneumonia (PJP, PCP). What will be important for the nurse to include in the nursing care plan?
Wear a gown and gloves when assisting the client with personal hygiene.
Which of the following are true statements about cocaine? Select all that apply.
1,2,4,5
The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply.
1,2,3
What are important points to include in the teaching plan of a client who is on lithium therapy? Select all that apply.
1,2,3,6
he daughter of a 75-year-old woman notices that her mother has mild memory impairment. During a clinic visit, the daughter asks the nurse if her mother is developing Alzheimer's disease. What would be appropriate information to explain about factors to distinguish normal age-related memory impairment from dementia associated with Alzheimer's disease? Select all that apply.
1.3.4.6
Which of the following best describes magical thinking in the mental health setting?
Believing thoughts or wishes can control other people and events
A client with manic depression client has been receiving lithium carbonate (Lithane). His serum level is 0.3 mEq/L. What is the interpretation of this level?
Below the desired range
The client was admitted to the psychiatric hospital with a history of increasing suspicion and hostility. During the admission interview, the client tells the nurse he knew he was followed to the hospital by spies hired by his co-workers. The nurse understands that this thinking is a:
Delusion of persecution
Which common substance(s) would an adolescent client most likely inhale to become intoxicated? Select all that apply.
1,2,4,5,6
Which of the following are common assessment findings on a rape-trauma victim during the long-term reorganization phase? Select all that apply.
1,3,4,5
The nurse is caring for a client with borderline personality disorder. Which would be included in the treatment plan for this client? Select all that apply.
1,4,6
The nurse is about to conduct an admission assessment on an 85-year-old female client who is admitted after falling down in her home. When determining the amount of time to set aside for the interview, the nurse will consider which of the following?
Allow ample time to gather psychosocial data from the client.
A client is experiencing a lack of logical thought progression, resulting in disorganized and chaotic thinking. The nurse understands this to be:
Associative looseness
A client has been experiencing a choking sensation or tightness in the throat, heart palpitations, dizziness, and feelings of fear and insecurity. Based on a history of these symptoms over several months, the nurse would anticipate administering which medication?
Chlordiazepoxide (Librium)
A client has been receiving memantine (Namenda) for moderate Alzheimer's disease (AD). How would the nurse know that the medication is effective?
Client is less agitated and more cooperative.
A client has been prescribed a benzodiazepine. The nurse knows that the most common adverse effect on the central nervous system is its action as a(n):
Depressant
An older adult client is experiencing alcohol withdrawal symptoms. What medication would the nurse anticipate to be ordered initially?
Lorazepam (Ativan)
The nurse is caring for a client who exhibits pinpoint pupils and decreased blood pressure, pulse, respiration, and temperature. The nurse understands that these symptoms may indicate:
Opiate intoxication
A female client has a black eye and bruises about the mouth, and the nurse suspects physical abuse. Which question from the nurse would be most appropriate?
"Can you tell me what happened?"
A client who has recently been diagnosed with end-stage lung cancer states, "I feel like I am going to die very soon." What is the nurse's best response?
"Can you tell me what makes you think you will die so soon?"
The mother of a 23-month-old child works in a factory at night and says if she misses any more work she will be fired. She is worried about leaving the child in the hospital at night because he is so young. What would be an appropriate nursing response?
"It would be better if you could stay, but we will take good care of him."
After a meeting with his wife and the nurse, a client expresses that his wife's nagging gets on his nerves. After the session, he asks the nurse if she will talk with his wife about her nagging. Which of the following would be the most therapeutic response to the client?
"Let's talk about how you might bring up this issue to your wife."
A mental health client reports to the nurse that the television is talking to her in a threatening manner. What is the nurse's best response to the client's verbalization about the television?
"That seems unusual. Thoughts may seem confusing when one is upset or frightened.
A client has come into the ER with severe vomiting and diarrhea, and he has been unable to keep any liquids down for about 24 hours. He tells the nurse he had a liver transplant 2 years ago. What would be most important for the nurse to ask?
"What immunosuppressant medications are you currently taking?"
Characteristics of borderline personality disorder include which of the following? Select all that apply.
1,2
Which assessment finding would lead the nurse to conclude that a female client may be HIV-positive? Select all that apply.
1,2
Which of the following statements are correct about latex allergy? Select all that apply.
1,3,5,6
A client is worried he may have been exposed to AIDS. What will be important for the nurse to explain to this client?
After exposure to the virus, symptoms may develop within 6 to 12 weeks or as late as 6 months.
In response to information that a 5-year-old's death is imminent, the parents express intense anger at the staff, and they are critical of the care he is receiving. What is the purpose of therapeutic intervention on the parents' behalf?
Allow them to express their emotions about his dying.
A client is experiencing difficulty breathing, periorbital swelling, flushing, and itching. He had a diagnostic test in which an iodine-based dye was used about an hour earlier. What medication will the nurse anticipate administering immediately?
An adrenergic agonist such as epinephrine (Adrenalin)
What medications are drugs of choice for treatment in secondary therapy for the client with an anaphylactic reaction?
Antihistamines and corticosteroids
A client who has been recently diagnosed as positive for the human immunodeficiency virus (HIV) asks the nurse about the medicine for the virus. The nursing response would be based on what concept?
Antiviral therapy is individualized and will be based on the client's CD4+ T cell count and the viral load.
A client is experiencing a severe allergic reaction. The nurse has secured an IV access and has administered epinephrine 1:10,000 0.5 mL IV. What is an additional critical nursing action for this client?
Begin oxygen at 100% with a non-rebreather mask.
The nurse is assessing a client who may be experiencing auditory hallucinations. Which client activity would assist the nurse to confirm that a hallucination is occurring?
Client mumbles to self, tilted head, eyes darting back and forth.
While interviewing a client who declines answering questions or responds minimally when providing a comment and rarely makes eye contact, the nurse should include which of the following in her documentation note of the assessment interview process?
Client's responses and specific content along with description of behavior
It has been 3 years since seroconversion for a client who is positive for the human immunodeficiency virus (HIV). The client currently has CD4+ T cell count of 700. What would the nurse explain to the client regarding this information?
Currently the body is producing an adequate number of CD4+ T helper cells to protect against the virus.
A client has been referred to a community mental health center. Her husband reports that she no longer participates in activities she previously enjoyed, sleeps poorly, and has lost 10 pounds in the last month. The nurse would anticipate the client to have a diagnosis of:
Depression
Which of the following signs and symptoms would the nurse assess for in a client with possible lithium toxicity?
Diarrhea, ataxia, seizures, lethargy
What conditions would indicate that a client who is suicidal is demonstrating self-restraint in carrying out the action?
Disclosing suicide plan to nursing staff
A young woman has just received news of a positive test for human immunodeficiency virus (HIV). She does not want her sexual partner to be informed. What is the most appropriate nursing response to her decision?
Discuss with the client the ethical responsibility to inform all sexual partners.
As part of a treatment program for alcohol abstinence, a client may benefit from which drug that interferes with the metabolism of the alcohol?
Disulfiram (Antabuse)
A client received 75 mg of diphenhydramine (Benadryl) for an acute atopic reaction and is now drowsy, talks slowly when asked a direct question, but responds correctly. What is the nurse's best action?
Document the response in the chart.
Which of the following medications is indicated for treatment of mild to moderate dementia associated with Alzheimer's disease?
Donepezil (Aricept)
A client is admitted to the inpatient psychiatric unit for medically monitored detoxification from alcohol. Which of the following actions would be included in the client's plan of care?
Encourage increased fluid intake.
Play therapy is scheduled for a „year-old boy who has been sexually abused by his mother. The goal for play therapy for this „year-old is to:
Encourage the child to communicate in his own language through play.
A client who has severe dementia no longer recognizes her son, and when he visits the unit, the client becomes anxious and agitated when the son attempts to reorient her and explain who he is. What would be an appropriate suggestion the nurse could make to the son?
Encourage the son to bring in photos and family albums to talk and reminisce.
The ER is notified that a child is being brought in who is having difficulty breathing. The mother reports a bee stung the child. Which medication should the nurse have available for the child's initial treatment?
Epinephrine
A child who weighs 30 lb (13.6 kg) arrives in the office with a complaint of an allergic reaction to peanuts. The child has hives on most of her body and is beginning to wheeze. The nurse anticipates administering:
Epinephrine (Adrenalin) 0.14 mL of a 1:1000 solution
What is an important aspect of planning nursing care for the suicidal client?
Establishing a support system
A woman explains to the nurse that she thinks she has been exposed to HIV. However, she had a test 1 week after the exposure and the result was negative. What is most important for the nurse to explain to this client?
Even though the client tested negative, she needs to have a series of follow-up blood tests because of the possibility of seroconversion.
What is a natural chemical defense found in the body, which works as a part of the body's immune system?
Gastric secretions
A client with AIDS has several cutaneous lesions identified as Kaposi's sarcoma. How will the nurse care for these areas?
Gently cleanse the areas, keeping them dry and free of abrasions.
The roommate of a client with acquired immunodeficiency syndrome (AIDS) comes to visit, follows the nurse out of the room, and says, "I am so scared I am going to get AIDS. I have been living with him." The nurse's response would be based on which principle?
HIV is spread by direct contact with the blood of an infected person and through sexual activity.
A client has been diagnosed with cancer of the liver and has metastasis to the brain. The chemotherapy is being discontinued because of unresponsiveness of the tumor. This client has been assigned on a regular basis to Nurse C. In planning nursing staff assignments, what would be important for the nurse manager to consider?
Having Nurse C continue to care for the client
A client who is positive for the human immunodeficiency virus (HIV) has been receiving antiviral medication for the past 3 months. He calls the clinic complaining of polydipsia, polyuria, and polyphagia. The nurse understands that these symptoms are most likely related to:
Hyperglycemia caused by the protease inhibitor
In developing a plan of care for a client with dementia, the nurse would consider which of the following as a primary concern?
Inability to make safe judgments
An older client states, "Life isn't so good, and I'm ready to just end it all." The best approach for the nurse to take at this time would be to:
Initiate a no-suicide contract with the client.
Which nursing assessment finding is commonly associated with a diagnosis of systemic lupus erythematosus (SLE)?
Joint pain, rash over the bridge of the nose rash, photosensitivity
The nurse is caring for a client who is diagnosed with delirium. What is a priority nursing measure to provide for the client?
Maintaining a safe environment
When attempting to establish trust and rapport with a client with schizophrenia, the nurse should focus on which priority action?
Make emotional contact.
A client's husband reports that over the past month his wife has become increasingly agitated and hyperexcitable, with a marked increase in verbal and physical activity. Based on these symptoms, the nurse concludes the client may be experiencing which of the following?
Manic episode
Which of the following nursing interventions should be instituted for a client experiencing a manic episode?
Place the client in a quiet area, separate from others.
A nurse case worker suspects older adult neglect. What assessment findings during a home visit would confirm this?
Poor nutrition and hygiene
A client is brought to the emergency room after being bitten by an insect. The client is anxious and is having difficulty breathing. What would be the first nursing action?
Position client to maintain open airway.
The nurse would anticipate which laboratory finding in a client with joint pain, butterfly rash, photosensitivity, weight loss, and fever?
Presence of antinuclear antibodies
The nurse is monitoring a client with a diagnosis of bulimia nervosa. In addition to monitoring the client's eating, what other nursing measure is important to perform after a meal?
Prevent the client from using the bathroom for 2 hours after eating.
A client with late-stage Alzheimer's disease has a nursing diagnosis of disturbed thought processes. What would be an appropriate nursing intervention for this problem?
Promote a consistent, regular daily routine.
A multidisciplinary approach is used for investigation of a family situation. Once the diagnosis of child abuse is established, a nursing care priority is:
Protecting the total well-being of the child
A client is brought into the neighborhood clinic. The family states he was eating dinner and began to have difficulty breathing. The client has a history of anaphylactic reactions. What signs and symptoms would the nurse identify as an anaphylactic reaction?
Pruritis, difficulty breathing, increasing anxiety
The nurse is caring for a client who is experiencing a severe anaphylactic reaction caused by an allergy to peanuts. After administering subcutaneous epinephrine and beginning oxygen administration, what would be the next most important nursing action?
Start an IV for fluid administration.
The nurse finds a client huddled in the corner of her room, staring out into space, and she seems to be responding to something not visible to others. Further assessment reveals that she is scared, hyperalert, and anxious. What might be an appropriate evaluation of the situation?
The client may be hallucinating.
The nurse is assessing the dietary history of a 16-year-old female client. Which symptom would indicate anorexia nervosa rather than bulimia?
The family states she refuses to stop her extreme dieting
The nurse is assessing the burn pattern on a toddler. An accidental scalding is suspected as the cause of the burn. What should the nurse look for regarding the pattern of the burn?
The front of the body is where scalding burns usually occur.
A client returns to the clinic to receive evaluation of his routine purified protein derivative (PPD) test for tuberculosis screening. The test result is positive. What is the best nursing interpretation of this information?
The positive results indicate the client has been exposed to the tuberculosis bacilli and has had a delayed type IV response.
A client comes into the clinic with complaints of general malaise, increased lethargy, and headaches. An enzyme immunoassay (EIA) is positive for serum antibodies associated with the human immunodeficiency virus (HIV). What will be important for the nurse to discuss with the client?
The test was positive; however, it must be repeated to verify the results.
The nurse is teaching a client about preventing the spread of HIV. The client asks the nurse why women are at greater risk than men for development of HIV disease through intercourse. The nurse's response is based on which of the following?
The vagina has a greater amount of mucous membrane surface than the penis.
Which of the following factors is the most important for the nurse working with the parents of an infant with Down syndrome?
Their ability to talk about caring for their child and anticipated changes in their lifestyle
A client has expressed suicidal ideation. The nurse uses the SAD PERSONS scale while interviewing the client. What type of data does the scale provide?
Triage suicide potential
The nurse is teaching a client about risk factors and prevention of transmission of human immunodeficiency virus (HIV). Which statement by the nurse is most accurate?
Unprotected oral sex with an infected partner is not advised.
Which sign and/or symptom is indicative of a type I hypersensitivity reaction?
Urticaria (hives)
A client is being admitted with abdominal pain and distention. The client expresses to the nurse that a brother was diagnosed with cancer of the liver 3 months ago. The client states that his brother is continuing to do fine even though he has decided not to have any follow-up treatment. When performing a psychosocial assessment on this client, what will the nurse expect the client to exhibit?
Withdrawn and will not discuss anything about cancer
Chlorpromazine (Thorazine) is ordered for a client. Which of the following signs/symptoms would the nurse include in the medication teaching about this drug?
drowsiness
A mental health client has suddenly developed an intense fear of heights. During a group therapy session, she makes the following statements, "I know my feeling of being terrified of heights is dumb. It doesn't make any sense. I just can't seem to do anything about it." Which response would be most appropriate for the nurse to make?
"Knowing that your fears don't make any sense doesn't seem to help you feel better."
The depressed client is crying; she sobs and says, "I'm so ugly and awful. Why do you come here?" The nurse's best response is:
"You feel so badly about yourself today. Let's talk about it."
The nurse is caring for a client with bulimia and a client with anorexia. What cognitive characteristics would both of these clients have? Select all that apply.
1,2
What is a priority nursing action in the care plan for a manic client with bipolar disorder?
Maintain nutrition.
A client with schizophrenia is incontinent and urinates on the floor. The nurse's best response would be to:
Clean up the urine without communicating displeasure.
A client experiencing severe depression is admitted to the inpatient psychiatric unit. During the initial assessment, she says, "I feel like killing myself, but I wouldn't do that because of my kids." The nurse's priority action would be to:
Determine the severity of her suicidal risk.
An older client has been experiencing confusion. The nurse is trying to determine whether the confusion is related to depression or dementia. In evaluation of the client, what specific nursing assessment finding(s) would be helpful in making this distinction?
Determining whether confusion worsens in the evening
The nurse is caring for a client whom she suspects is paranoid. What is an appropriate approach when communicating with this client?
Direct questioning
The nurse is caring for a client with schizophrenia, catatonic type. The client refuses to eat. What is the best nursing action?
Gavage feed the client with nutritional liquids.
The school nurse is monitoring several children with attention-deficit/hyperactivity disorder (ADHD) who are taking methylphenidate (Ritalin). The nurse should conduct monthly follow-up examinations to monitor:
Growth in height and weight gain
The nurse is assessing the mental status of an older adult woman diagnosed with dementia. The client answers the nurse's questions by mumbling in low tones with answers that seem inappropriate. What would be initial assessment findings associated with a diagnosis of dementia?
Has short-term memory loss and is confused
Which of the following findings should the nurse expect when completing the admission assessment for a client with borderline personality disorder?
Impulsiveness and self-damaging, unpredictable behavio
During the admission procedure for a client with a diagnosis of schizophrenia, catatonic type, the client demonstrates "waxy flexibility." What are the characteristics of this behavior? The client:
Keeps the arm raised long after the nurse has finished taking the blood pressure
What would be an essential nursing intervention for suicide precautions?
Maintain a one-to-one contact with the client.
The nurse would recognize that typical nursing assessment findings in a client experiencing anxiety are:
Palpitations, sweaty palms, and shortness of breath
A client tells the nurse that he can't eat his dinner, because the food has been poisoned. The nurse describes this behavior as an indication of which of the following?
Paranoia
A client demonstrates an inappropriate affect by giggling while talking about her brain being destroyed. This behavior serves what purpose for this client?
Protects her against the painful emotional impact of what she fears is happening to her
When caring for a client with dementia, which of the following is a priority?
Providing a safe environment for the client
A client with a diagnosis of schizophrenia repeatedly states, "There are flies eating my brain and making me feel weird." The client is most likely experiencing which of the following?
Somatic delusions
The client who has been receiving haloperidol (Haldol) on a long-term basis begins to exhibit bizarre facial and tongue movements. Based on these findings, the client is most likely exhibiting signs and symptoms of which disorder?
Tardive dyskinesia
The nurse would identify the need for further teaching when the family of a rape victim does which of the following?
Tries to distract the victim from thinking or talking about the rape
A client has been diagnosed with rape-trauma syndrome and is being seen in the emergency department. In planning the client's discharge, what finding would the nurse expect to see as a short-term outcome for this client? The client will state that she:
Will make a follow-up appointment with the rape crisis center
