Missed Questions

A nurse is caring for a client with bipolar disorder who is experiencing mania. what action is the nurse's priority a. offer the client finger foods every 2 hours b. determine if the client is a danger to herself c. monitor the clients vital signs every 2 hours move the client to a quiet area

Determine if the client is a danger to herself rationale: The greatest risk to this client is an injury from hyperactivity or life-threatening exhaustion.

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety a. varenciline b clonidine c. buprenorphine d. disulfiram

Disulfiram rationale: disulfiram is a type of aversion therapy that helps clients abstain from alcohol drinking alcohol while taking this medication produces a toxic reaction that causes vomiting confusion headaches breathing difficulties and other manifestations

A nurse is caring for a client who has antisocial personality disorder. which of the following actions should the nurse take. A. encourage the client to attend assertive behavior seeions B. Ensure staff members set limits on the client's behavior C. Tell the client to increase socialization on the unit D. Frequently implement measures to increase the client's self-esteem

Ensure staff members set limits on the client's behavior Rationale:The nurse should ensure that all staff members set limits the limits should be clear and realistic and pertain to specific behaviors, also the nurse should provide clear boundaries and consequences.

A nurse is preparing to meet with a client who has borderline personality disorder. what actions should the nurse plan to take during the working phase of the therapeutic relationship

Facilitate a change in the client's behavior Rationale: The nurse should facilitate a change in the client's behavior during the working phase of the therapeutic relationship

A nurse is assessing a client who has adjustment disorder which of the following statements by the client should the nurse recognize as a manifestation of this disorder

I could have done something to prevent my cousins death

a nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. the nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching

I will not take charge of my partner's work responsibilites

a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorder. which statement by the newly licensed nurse indicates an understanding of the teaching?

I will update the plan as a client's manifestations of depression change

A nurse is determining the total score for a client's alcohol use disorder identification test (AUDIT) by assigninga score of 1 to4 for each answer for which of the following findings should the nursse assign the client a score of 4 A. The frequency of alcohol intake is typically 3 times per week B. The client misses work once a month because of alcohol intake C. Alcohol intake does not cause the client to have feelings of guilt. D. Last month the provider suggested the client should reduce alcohol intake

Last month the provider suggested the client should reduce alcohol intake Rationale: When determining a clients total score for the audit self-reported version the nurse should assign a score of 4 if the client indicates that a friend relative or healthh care provider has recommended decreasing alcohol consumption at least once during the last 12 months

A home health nurse is assessing a client who has advanced dementia and whose caretaker recently passed away. the client is not violent or suicidal. what settings should the nurse make a referral for this client

Long term care nursing center patient has advanced dementia

A nurse in a providers office is assessing a client who is crying and states, "it's my child's first day of school." The nurse should recognize that the client is experiencing what type of loss

Maturational loss

an emergency room nurse is assessing a client who has anxiety disorder. the client is flushed perspiring profusely and experiencing palpitations. the client begins to scream. I am going to die! this is it! I am having a heart attack. the nurse should determine the client's level of anxiety to be which of the following. a. moderate b. panic c. severe d. mild

Panic rationale: This client's manifestations indicate the panic level of anxiety and manifestations of a panic disorder.

a nurse is conducting a risk assessment for clients who are prescribed medications that can cause orthostatic hypotension. which of the following medication requires a follow up by the nurse. a. phenelzine b. escitalpram oxalate c. galantamine d. naltrexone

Phenelzine Rationale: its MOAI is prescribed for depression and other mental health disorders. and adverse effect of phenelzine is orthostatic hypotension. the nurse should inform the client who is taking phenelzine that dizziness and lightheadness are indications of hypotension.

A nurse is caring for a client who has neurocognitive disorder and wanders at night. which of the following actions should the nurse take to hlep keep the client safe? A. put the clients mattress on the floor keep the lights off in the client's room at night c. limit snaks during evening hours Turn off the clients radio or music player at night

Put the clients mattress on the floor Rationale: This action reduces the client's risk of injury from falling out of bed when the client is confused or getting up to wander.

A nurse is caring for a client with ADHD who recently started taking lithium for which of the following findings should the nurse monitor when evaluating the effectiveness of the medication

Reduced aggression Rationale: ADHD can experience a low tolerance for frustration which can result in aggressive behaviors, although psychosocial interventions should include developing coping mechanisms and cbt the client might require medicaton to manage aggressive behaviors

a nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. which of the following interventions should the nurse include in the plan? a. document the client's behavior every 8 hr b. limit the client's fluid intake to 50ml/hr c. renew the prescription for the client every 4 hr. d. toilet the client every 4 hr

Renew the prescription for the client every 4 hours. the nurse should assess the client's behavior frequently during seclusion and should renew the prescription for the seclusion for an adult clietn every 4 hr for a max of 24 hr.

A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. for which of the following should the nurse withhold the dose a. report of nausea with requent episodes of emesis b. weight gaim fine hand tremors in both hands serium lithium level of 1.1

Report of nausea with frequent episodes of emesis

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine the client still has a current rx for sertaline. the nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects

Serotonin syndrome Rationale: Tranylcypromine is an MAOI and sertaline an SSRI you should not mix MAOI simultaneously. manifestations include delirium, abd pain, muscle spasms and irritability and the condition can worsen to cause cv shock and death.

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. the client has developed involunatry writhing movements of the tongue and constant lip smacking. the nurse should identify that these manifestations indciate which of the following adverse effects of haloperidcol A. akathisia b. acute dystonia c. TD D. pseudoparkinsonism

TD tardive dyskinesia Rationale:TD can be manifested by involuntary movements of many body parts. Early findings include writhing movements of the tongue and smacking of the lips the nurse should report these manifestations to the provider immediately because the findings might not be reversible and can progress to affect all extremities.

A nurse is caring for a client who requests information about smoking cessation using nicotine gum. for which of the following reasons should the nurse recommend another otc smokign cessation product

The client has dentures

A nurse in an emergency department is assessing a client who has bipolar disorder and is in a manic state. Which of the following findings is the highest priority a. The client reports sleeping 2-3 hours per night B. The client speaks to the nurse in a demanding tone C. The client reports not attending group therapy.

The client reports sleeping 2-3 hours per night Rational: The greatest risk to this client is an injury from exhaustion due to lack of sleep.

a nurse is discussing a 12 step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. which of the following information should the nurse include in the teaching the progam will help the client accept responsibility for the disorder the client should obtain a sponsor before discharge for an increased chance of recovery the client will need to identify individuals who have contributed to the disorder. the program will need a prescription for the client's provider prior to attendance.

The client should obtain a sponsor before discharge for an increased chance of recovery. rational: the nurse should teach that peer support has been shown to increase program attendance and the chances of recovery if the client does not have a sponsor they can be assigned one when they begin attending the program.

A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving a. the death was a result of violence b. the client expresses anger over the loss c. this is the clients first experience of the loss of a family member D. the client demonstrates reorganizaton of behavior

The death was a result of violence rationale: when death is a result of violence is traumaic or is unexpected the loss can result in maladaptive grievign for those left behind.

A mental health nurse is reviewing a process of recording of a therapy session with a client, which of the following statements should the nurse identify as an example of the communication technique of reflection a. i notice you are pulling on your hair when we discuss your dismissal b. That statement made by other client appears to have upset you c. since writing in your journal is frustrating we should look at his activity more closely d. give me an example of a time when you felt no one understood you.

The statement made by the other client appears to have upset you Rationale: reflective statements are useful in assisting a client with identifying emotions and ideas. this therapeutic communication technique validates the ciients emotions and encourages the client to reflect more deeply on the emotion

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client

Therapeutic communication builds a relationship that will allow expression of mutual concerns

a nurse is assessing a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication a. arthralgia b. photophobia c. xerostomia d. bradycardia

Xerostomia rationale: buspirone can cause xerostomia or dry mouth. other adverse effects include headache, nausea, and insomnia

A nurse on a psych unit is talking wiht a client when the client makes a sexual advance toward the nurse

You need to stop any type of sexual advances

a nurse is receiving changes of shift report for four clients which of the clients should the nurse plan to see first?

a client who is taking clozapine and reports a sore throat and chills rational: when using the urgent vs nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. clozapine can cause agranulocytosis a serious adverse effect that causes...

NGN Question A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumantic event. The nurse is providing teaching to the clietn which of the following statements should the nurse include in the teaching (select all that apply) Exhibit 1 vital signs 0730 temp 36.6 (97.8) HR 74/min RR 16/min b/p 118/74 mm hg 1400 temp 36.9 (98.4) HR 86/min RR 18 min b/p 114/78 a. you should seek help if you have thoughts of self-harm b. a support group might be helpful to you during this time c. you will have minimal problems performing your daily self-care tasks d. it is common for people who survived a traumatic event to experience feelings of anxiety e. it is uncoomon for people who survived a traumatic event to experiences spiritual distress

a. you should seek help if you have thoughts of self-harm b. a support group might be helpful to you during this time d. it is common for people who survived a traumatic event to experience feelings of anxiety clients who have experienced a traumatic event can experience spiritual distress

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. the clients is being prepared for discharge following his fourth admission in the last year. which of the following referrals should the nurse make or the client first

aSSERTIVE COMMUNITY TREATMENT

a nurse in the emergency department is caring for four clients. which of the following clients is the nurse required to report as a potential victim of abuse

an older adult client who is bedbound and has a stage IV pressure ulcer

a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. the nurse should identify that which of the following treatment options can offer interdiscplinary services for the client at home

assertive community treatment

a nurse is collecting data from a client with schizophrenia who was recently admitted to acute care which of the following findings should the nurse expect. a. sedcutive behaviors b. obsession with rituals c. uncontrolled appetite d. associative looseness

associative looseness rationale: associative looseness (speech that reveals thought patterns that shift rapidly from one topic to another) as a common finding for a client who has schizophrenia other findings include the presence of delusions, hallucinations and altered speech patterns sucha s echolalia

a nurse on a mental health unit observes a client who has acute mania hit another client

call for a team o fstaff members to help with the situation

a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. which of the following assessment findings supports the nurses suspicion of delrium

easily distracted extreme distractibility is a hallmark manifestation of delirium

a nurse is caring for a client who has a personality disorder nurse notes day 1 admit note 0700 talkative well groomed states she is looking forward to divorcing partner number four because she has found my next partner anxious if left alone-wants to remain close to nurse tells the nurse I feel like a bomb waiting to explode for each potential provider's prescription click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia or borderline personality disorder. each therapy can support more than one disease process

fluoxetine obsessive borderline personality donepezil- obsessive, borderline personality dialectical- borderline personality disorder validation- demenita systematic- obsessive

a nurse is assessing a client who has oppositinal defiant disorder. which of the following findings should the nurse expect a. displaying a flat affect b. unmotivated by rewards c. ignoring unit rules d. fearing a loss of privileges

ignoring unit rules ratinonale the nurse should expect a client who has oppositional defiant disorder to ignore and break the rules

NGN Question a nurse is caring for a client who has a personality disorder nurse note day 1 admit note 0700 talkative, well-groomed states she is looking forward to divorcing partner number four because she has found my next partner anxious if left alone-

incidences of self injury married multiple times stealing money from family to cover credit card charges hypersexualization physcial altercations anxious if left alone

a client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. the client who has depression reports to the nurse. my roommate never sleeps keeps me up too. which of the following actions should the nurse take

move the clietn who has bipolar disorder to a private room clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. therefore the nurse should move the client to a private room

a nurse is planning care for a client who has made repeated physcial threats toward others on the unit. although the client does not want to leave the unit. the nurse requests the provider to transfer the clietn to a unit that is equipped to manage violent behavior. which of the following ethical principles should the nurse apply in this situation?

nonmaleficence it tis the responsibility fo the nurse to do no harm to others. or clients. the nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury to others on the unit.

a nurse is preparing to discharge an older adult client who attempted suicide the client lives alone and has difficulty performing ADL's which of the following referrals should the nurse initiate?

occupational therapy meal delivery services physical therapy home health services

a nurse is assessing a family's dynamics during a counseling session. the nurse should recognize which of the following findings as an indication of a boundary issue

older children who are responsible for their younger siblings this is an example of enmeshed boundaries in which there are no distinctions between the roles of family members

a nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. which of the following over the counter medications that the client reports taking should alert the nurse to a potential adverse reaction? a. lansoprazole b. naproxen c. magnesium hydroxide d. phenylephrine

phenylephrine clients who are taking trancylcypromine and MAOI should not take phenylephrine and other otc meds for sinus congestions colds or allergies due to thier actions on they sympathetic nervous system can cause severe hypertension

ngn a nurse is caring for a client who has a personality disorder nurses notes day 1 admit note 0700 talkative well groomed, the client is at risk for developing ------ as evidence by the clients---------

the client is at risk for developing VIOLENT BEHAVIOR as evidence by the client's INCERASED AGITATION

a nurse is assessing a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea a headache and extreme thirst the nurse should identify that which of the following situations is occurring a. the client is experiencing mild acetaldehyde syndrome b. the client is experiencing delirium tremens c. the client is experiencing disulfiram toxicity d the client is not having a therapeutic response to disulfiram

the client is experiencing mild acetaldehyde syndrome rationale: the nurse should recognize that these manifestations are an indication of acetaldehyde syndrome wich occurs when alcohol consumption is comined with disulfiram use.

a nurse is assessing a client who has bulimia nervosa. the nurse should expect which of the following findings?

tooth erosion a client who has bulmia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting

NGN question a nurse at a providers office is interviewing an older adult client. which of the following actions should the nurse plan to take? (click on the exhibit button for additional information about the client. there are three tabs that contain separate categories of data.) Nurse notes The client reports a history of anxiety diagnosed with alzheimers disease 2 months ago. The client's partner died 6 months ago. Reports decreased appetitie low energy levels and insomnia for several week some memory loss use a screenign tool to evaluate the client for depression b. ask the provider to decrease the dosage of the client's blood pressure medication c.blah blah blan

use a screening tool to evaluate the client for depression rational: depression can be underdiagnosed among older adult clients. the nurse should identify several risk factors for depression from the clients data including having Alzheimer's disease anxiety and the loss of a loved one. manifestations of depression can also be nonspecific for older adult clients and can include weight loss decreased energy levels and difficulty sleeping

A nurse is caring for a client who has post traumatic stress disorder and who is undergoing eye movement desensitation reprocessing EMDR the nurse should identify that EMDR includes which of the following strategies

uses stimuli to change how the client processes the trauma Rationale: uses stimuli such as tapping, eye movements, or audio sounds combined with verbalization of the traumatic event by the client.