Nclex 7

The nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

"I cannot promise to keep a secret."

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be the most appropriate?

"What do you and your husband believe is the right thing for your children?"

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?

Client involvement in goal setting

The nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. Which finding requires the nurse's immediate intervention?

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan?

Arrives at the clinic neat and appropriate in appearance

Treatment that involves pairing a stimulus attractive to the client with an unpleasant event is known as which type of therapy?

Aversion therapy

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which?

Conversion disorder

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is which?

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

Gastrointestinal dysfunctions

A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

No rapid heartbeats or anxiety

The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

The nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

The nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is which?

Ping-Pong

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

Psychomotor retardation and side effects of medication

A client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of bupropion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which?

Seizure activity

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide.

The nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

White blood cell count

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

Weight loss