N481 HESI Practice
which action would the school nurse take for a child who tells the nurse, "My father has been getting into bed with me at night and touching me"?
report the child's conversation to child protective services
which client statement indicates that the client is experiencing a maturational crisis? moved out of parents house divorce problem with nursing professor vague feelings of uneasiness
"I just moved out of my parent's house; I should be happy, but I feel overwhelmed"
which priority concern would the nurse monitor for while working with clients withdrawing from cocaine?
risk for self-injury
symptoms of neuroleptic malignant syndrome
-hyperthermia (fever), muscle rigidity, autonomic instability and mental status changes, sweating, tachycardia -elevated CK, leukocytosis -metabolic acidosis
which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is the president?
schizotypal magical thinking, odd beliefs, strange speech patterns, and inappropriate affect
which type of group is Alcoholics Anonymous?
self-help group
A client reports to the nurse, "I'm afraid of every little thing and I have a fear of dying. My heart races all the time, and I break out in sweats." Which first-line medications would the nurse anticipate developing a teaching plan for? sertraline fluoxetine phenelzine alprazolam imipramine
sertraline, fluoxetine
which intervention will the nurse use for a client diagnosed with borderline personality disorder to develop healthier coping mechanisms?
set realistic limits on maladaptive behavior
which action would be difficult for a client who has borderline personality disorder to complete during the orientation phase of a therapeutic relationship?
setting mutual goals for the relationship
which conclusion would the nurse make about a depressed, suicidal client who greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long"?
increased risk of suicide
which biophysical need is the priority in the acute phase of bipolar disorder, manic episode?
physical
Which activity would be appropriate for the nurse to introduce to a depressed client during the early part of hospitalization? board game project involving drawing intense aerobic exercise group card game with three other clients
project involving drawing
which nursing intervention would be most important for a client who has a diagnosis of antisocial personality disorder?
providing clear boundaries and consequences
which clinical manifestation is associated with depression? flight of ideas suspicion of others psychomotor retardation intrusive social behavior
psychomotor retardation
which action by the nurse would decrease the risk of injury for a child with oppositional defiant disorder?
redirect anger in other ways
which disorder would the nurse classify as neurodevelopmental? anxiety bipolar disorder schizophreniform disorder ADHD
ADHD
the nurse is caring for a client take an SSRI for depression. which statement by the client requires additional teaching? "I should take the medication at the same time daily" "I can stop taking this medication when I feel better" "I will exercise to control any weight gain the medication might cause" "I need to report any agitation I experience to the health care provider"
I can stop taking this medication when I feel better
an older adult client reports flashbacks related to his experiences in Vietnam; he exhibits startle reactions and poor concentration. which mental disorder is associated with these symptoms?
PTSD
which behavior indicated codependence for the spouse of a partner who abuses multiple drugs?
attempts to cover up the partners drug use
which type of hallucinations is the most common?
auditory
which behavior is most commonly used by an individual with a phobic disorder?
avoidance
which statement is accurate for adolescent suicide behavior? boys account for more attempts compared to girls girls use more dramatic methods compared to boys girls talk more about suicide before attempting boys are more likely to use lethal methods than are girls
boys are more likely to use lethal methods than are girls
which clinical finding is a positive sign or symptom for a client with the diagnosis of schizophrenia? anergy flat affect social withdrawal disorganized thoughts auditory hallucination
disorganized thoughts, auditory hallucinations
the client reports screaming hysterically whenever a spider comes close to her. which defense mechanism is the client using?
displacement
which action would the nurse take when working with a client who is depressed? accept what the client says attempt to keep the client occupied keep the client's surroundings cheery try to prevent the client from talking too much
accept what the client says
which action would be required of the client with an alcohol use disorder who attends alcohol anonymous meetings?
acknowledging an inability to control the alcoholism
the nurse is teaching the parent of a 6 year old child with ADHD about the administration of methylphenidate. which statement by the parent indicates an understanding of when they should administer the medication?
after breakfast
which point in the daily routine correctly describes when clients who experience alterations in perception tend to have more problems with vivid hallucinations?
after going to bed
which information would support the nurse's decision to arrange for a staff member to remain with a depressed client continuously? refusal to eat any food inability to concentrate agitated pacing in the hall history of suicide attempts statements that life is not worth living
agitated pacing in the hall, history of suicide attempts, statements that life is not worth living
which clinical manifestation would the nurse assess for in a client a few hours into alcohol withdrawal? agitation tremulousness yawning convulsions profuse diaphoresis
agitation, tremulousness
Which substance is the CAGE questionnaire used to screen?
alcohol
Which substance listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is considered addictive and therefore, a substance of possible abuse? alcohol caffeine cannabis hallucinogens gambling antianxiety medications
alcohol, caffeine, cannabis, hallucinogens, antianxiety medications
which primary anxiolytic medication would the nurse anticipate developing a teaching plan for when a client with social anxiety disorder has a history of exhibiting an intense, irrational fear of being scrutinized by others? sertraline paroxetine alprazolam venlafaxine clonazepam
alprazolam, clonazepam
which symptoms are classified as negative symptoms for a client diagnosed with schizophrenia?
anergy, anhedonia
which term describes a client who states that she no longer enjoys any of the activities that she once found fun and pleasurable?
anhedonia
which reaction is most likely to occur when the performance of a ritual is interrupted for a client with OCD?
anxiety
which behavior is characteristic of oppositional defiant disorder?
argues with adults
which time indicates when the nurse would be alert to the possibility of a depressed client acting out suicidal thoughts?
as the depression lifts
which approach would the nurse use for a delusional client who refuses to eat because of a belief that the food is poisoned?
refusing to argue about the food being poisoned
which behavior is characteristic of panic during a crisis? being physically immobile sobbing for no apparent reason difficulties with falling asleep startling to loud noises and touch
being physically immobile
which signs and symptoms would the nurse observe in clients with anorexia nervosa? cachexia purging diarrhea hypertension lanugo
cachexia, purging, lanugo
which antiseizure medication would the nurse identify as being used to stabilize a client's mood by suppressing mania associated with BPD? lithium quetiapine ziprasidone carbamazepine divalproex sodium
carbamazepine, divalproex sodium
When planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take? check on client frequently keep the client's room lights dim address the client in a loud, clear voice restraint the client during periods of agitation
check on the client frequently
which foods should the client receiving MAOI avoid?
cheese, beer, and products with chocolate
during an admission interview, a client is expansive and distractible and demonstrated a fragmented, pressured, nonsequential pattern of speech. which communication technique would the nurse use?
closed questions
which medications is most likely to cause metabolic side effects (weight gain, elevated lipid and blood glucose levels)?
clozapine, olanzapine
an older adult seems to make up stories to fill in for memory lapses. which behavior is the client displaying?
confabulating
which strategy would the nurse use to help a depressed, withdrawn client who exhibits sadness through nonverbal behavior?
cope with painful feelings by sharing them
which term describes the disturbance in mood and affect seen in clients who are depressed?
dysphoric
which factor is related to safety when discussing standards for involuntary admission to a mental health facility? mental illness severe disability currently cutting needs treatment
currently cutting
the serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. which assessment findings would the nurse expect? elevation in mood decreased coordination vomiting diarrhea decreased mania
decreased coordination, vomiting, diarrhea
which term would the nurse use to describe the thought processes of a client who insists that they are the commander of an alien spaceship despite repeated reality orientation?
delusion
which clinical manifestations would the nurse assess for in a client experiencing marijuana withdrawal? depression chills red eyes abdominal pain increased appetite
depression, chills, abdominal pain
which assessment finding would the nurse observe in a client with schizoid personality disorder?
detached and socially distant
which actions would be included in the safety plan for a woman in crisis, who is emotionally and physically abused by her husband? limiting contact with the abuser determining a safe place to go in an emergency memorizing the domestic violence hotline number obtaining a bank loan to finance leaving the abuser arranging to a family member to assist in her leaving
determining a safe place to go in an emergency, memorizing the domestic violence hotline number
which initial action would the nurse plan to take for a newly admitted client diagnosed with bipolar I disorder, manic episode?
encourage increased nutritional intake
which benefit is provided by milieu therapy? availability of individual and family therapy positive reinforcement to reduce guilt revelation of unconscious conflicts and fantasies environment provides structure, routine, and security
environment provides structure, routine, and security
which short-term client outcome would be priority for a client who has attempted suicide? strengthening coping skills establishing a no-suicide contract learning problem-solving techniques recognizing why suicide was attempted
establishing a no-suicide contract
which additional clinical manifestation would the nurse monitor for in a client with GAD who presents with restlessness and fatigue?
excessive worry
which characteristic of clients with antisocial personality disorder would the nurse consider when planning care?
exhibits lack of empathy for others
which behavior would the nurse observe in a client who has a histrionic personality disorder?
extroverted and dramatic
Which primary purpose foes the DSM-5 serve?
facilitates classification of mental disorders and guides the determination of diagnosis
which approach would the nurse use to help a client with bipolar disorder who is aggressive and disruptive in group and social settings develop social skills?
facilitating one-on-one interactions
which type of sexual disorder describes a client who has a sexual obsession with shoes?
fetishistic
which term is used to document the client's affect, which was observed during the mental status assessment? depressed flat cooperative resistive
flat
which guideline would the nurse consider when caring for clients who are at risk for suicide?
formal suicide plans increase the likelihood that a client will attempt suicide
which substance can cause life-threatening dysrhythmias when inhaled? glue gasoline nicotine cannabis paint thinner
glue, gasoline, paint thinner
which long-term outcome would the nurse use for a child who has conduct disorder?
has no physically aggressive episodes for 3 months
which feeling is a depressed, suicidal client most likely to verbalize? helplessness hypervigilance isolation indecisiveness hopelessness dominance
helplessness, isolation, hopelessness
which priority approach would the nurse take for a newly admitted client who is found to be experiencing command auditory hallucinations?
identifying the content of the messages in the auditory hallucinations
which behavior is most typical for clients with borderline personality disorder? arrogant eccentric impulsive dependent
impulsive
which rationale explains why the client who is displaying hyperactive and manic behaviors with flights of ideas is not eating?
is too busy to take time to eat
which term or phrase would the nurse chart about thought processes to describe a client diagnosed with schizophrenia who says, "Yes, it's March. March is Little Women. That's literal, you know"?
loose associations
which behavior is the client displaying when pretending to be ill?
malingering
which factor would precipitate a client's use of confabulation?
marked memory loss
an obviously upset client pushes ahead of the other clients and states, "I had an argument with my daughter, and now I'm tense, and anxious, and angry." Which level of anxiety is the client experiencing?
moderate moderate- focused on one part of reality but is unable to grasp the total picture mild- individual is cognizant of all aspects of reality but has "butterflies" panic- individual is no longer in contact with reality, is unable to make decisions, has impaired judgement, and is dysfunctional severe- lose touch with reality and have a feeling of impending doom, which tends to immobilize them
which term describes the client's use of made-up words that have no meaning to other people?
neologisms
which substance would pose the greatest risk of addiction for clients attending an alcohol rehabilitation program? heroin cocaine nicotine phencyclidine
nicotine
which intervention is the most important for a client who is diagnosed with bulimia nervosa? watch for pilfering and hoarding of food encourage eating meals in the public dining area assess for mood swings after eating observe for amount consumed and purging
observe for amount consumed and purging
which interventions would the nurse implement when a client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit? obtain vital signs assess for suicidal thoughts institute continuous monitoring initiate a therapeutic relationship inspect the bandages for bleeding say "you have so much to life for"
obtain vital signs, assess for suicidal thoughts, institute continuous monitoring, initiate a therapeutic relationship, inspect the bandages for bleeding
which behaviors describe an individual with cluster A personality disorder?
odd and eccentric
place the clients in order from highest risk for life-threatening physiological withdrawal to the one with the lowest risk older adult who is withdrawing from alcohol an adolescent withdrawing from cocaine young adult withdrawing from long-acting benzo middle aged adult who is withdrawing from marijuana
older adult, benzo, cocaine, marijuana
which universal characteristic is seen in children with ADHD?
overreaction to stimuli
a hostile client with the diagnosis of schizophrenia, says, "the voices are saying that they are going to poison me because I'm bad." which type of schizophrenic behavior is the client displaying?
paranoid
which characteristic is associated with anorexia nervosa? manic rebellious hypoactive perfectionistic
perfectionistic
which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"?
persecution
what is the correct order of phases a client experiences in the event of a change in body image?
shock, withdrawal, acknowledgement, acceptance, rehabilitation
which interpretation would the nurse make about a depressed client with mild suicidal ideation who has no plan, but has adequate family support and attends church regularly? should be at no risk for suicide warrants one-on-one observation warrants placement in a seclusion room should be reassessed at intervals regarding suicidal intent
should be reassessed at intervals regarding suicidal intent
which description is correct for Alzheimer disease?
slow, relentless deterioration of the mind
a client who is addicted to heroin has major surgery. afterward, the client received methadone. which purpose does the methadone serve?
switches the user from illicit opioid use to use of a legal drug
which initial action would the nurse take for a client with bipolar I disorder, manic episode who becomes loud and vulgar and disturbs the other clients?
take the client to a large, quiet area to walk
a client monopolizes the group therapy discussion and the other group members become inattentive. which intervention is best? gently telling the client that they are taking up too much of the group's time saying nothing and waiting for one of the group members to interrupt the monopolizer thanking the client for sharing and asking other group members to contribute confronting the client by stating that the group is not really interested in their topic
thanking the client for sharing and asking other group members to contribute
which assessment finding is associated with depression? the client has islands of intact memory the client has impaired recent and remote memory the client has impaired recent and immediate memory the client needs step-by-step instructions for simple tasks
the client has islands of intact memory
which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa?
the client has near ideal weight and behavior can seem normal
which situation would indicate the need for naltrexone to be administered?
to decrease the recovering alcoholic's desire to drink
which purpose is the focus of milieu therapy?
to manipulate the surroundings to facilitate positive changes in behavior
which rationale explains the function of obsessions and compulsions for a client with OCD?
unconscious control of unacceptable feelings
which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders? emotional cause feeling of illness restriction of activities underlying pathophysiology
underlying pathophysiology
which action would the nurse take to establish trust in a depressed client?
visit frequently for short periods with the client each day
