Pearson Questions
C. Offer fruit juice, soft drinks, or water every two hours while awake.
The nurse wishes to improve the hydration status of the confused client. Which action should the nurse take? A. Instruct a family member to sit with the client and offer fluids frequently. B. Place a pitcher of water at the bedside. C. Offer fruit juice, soft drinks, or water every two hours while awake. D. Instruct all staff members to stop by and offer fluids frequently.
B. Irritability D. Argumentativeness
The parent of a child recently diagnosed with oppositional defiant disorder (ODD) asks the nurse to name behaviors associated with the condition. Which information should the nurse include in an answer? Select all that apply. A. Arson B. Irritability C. Cruelty D. Argumentativeness E. Stealing
D. "Try having your child repeat what was said before starting the task."
The parent of a child with attention deficit hyperactivity disorder (ADHD) tells the nurse that the child doesn't follow instructions well. Which strategy should the nurse recommend to the parent? A. "It could be helpful to assign a time out if instructions aren't followed." B. "Consider developing a predictable daily routine." C. "Teach your child to be less aggressive and more assertive." D. "Try having your child repeat what was said before starting the task."
B. Restlessness and irritability C. Potential for seizures D. Fluctuating level of awareness
A client is admitted for treatment of alcohol withdrawal delirium. What items should be of high priority to address when the nurse writes the client's care plan? Select all that apply. A. Impaired individual coping B. Restlessness and irritability C. Potential for seizures D. Fluctuating level of awareness E. Self-esteem enhancement
B. The recent cognitive changes, if untreated, can lead to death. C. The client is at risk for injury. D. The client is experiencing symptoms of delirium. E. The behavior is impulsive.
A client is admitted status post-hip replacement; her medical history is otherwise benign. She is placed on morphine sulfate intravenously as needed for surgical pain. Soon she begins to mumble and becomes confused and combative. What conclusion should the nurse draw? Select all that apply. A. The client is experiencing symptoms of vascular neurocognitive disorder. B. The recent cognitive changes, if untreated, can lead to death. C. The client is at risk for injury. D. The client is experiencing symptoms of delirium. E. The behavior is impulsive.
C. Physical comfort and safety
A client is brought to the emergency room after a brutal physical assault. Although oriented and coherent, the client cannot remember the assault or events surrounding it. Which nursing intervention should be the priority of the nurse? A. Frequent reality orientation B. Referral to a community support group C. Physical comfort and safety D. Thoughtful questioning for the police report
D. Feelings like "being in a dream" E. Feeling like a robot
A client is diagnosed with depersonalization/derealization disorder. Which client data is the nurse likely to gather during the assessment? Select all that apply. A. Indifference to the symptoms B. Two or more personalities C. Amnesia about the event D. Feelings like "being in a dream" E. Feeling like a robot
C. The client will describe three stress management techniques by day two.
A client reports episodic depersonalization experiences to the nurse. Which of the following would be an appropriate goal of care? A. The client will report no suicidal thoughts by week one. B. The client will create a chart of all personalities by week one. C. The client will describe three stress management techniques by day two. D. The client will state five personal strengths by day two.
C. Risk for violence inflicted on self
A client with dissociative identity disorder (DID) is admitted after an overdose of alcohol and benzodiazepines, claiming that "another alter did it." The nurse should formulate which of the following as the priority nursing concern? A. Anxiety B. Posttraumatic stress syndrome C. Risk for violence inflicted on self D. Personal identity disturbance
C. Changing to a child alter
A client with dissociative identity disorder (DID) suddenly begins to speak with a child's vocabulary and voice. The nurse should interpret this as which of the following? A. An attempt to gain attention B. Malingering C. Changing to a child alter D. A state of depersonalization
B. "Can you tell me what is happening?"
A client with dissociative identity disorder (DID) suddenly has a change in voice quality and sentence structure. What is the most therapeutic response by the nurse? A. "This behavior keeps you from working on your problems." B. "Can you tell me what is happening?" C. "I wonder why you're not acting your age." D. "You must be feeling very needy."
B. Potential for injury related to cognitive deficits
A client with mild neurocognitive disorder due to Alzheimer disease often wanders because of confusion and becomes lost. Which priority nursing concern should the nurse select to address this behavior? A. Verbal communication difficulties related to anxiety B. Potential for injury related to cognitive deficits C. Confusion related to impaired cognition D. Anxiety related to fear of cognitive deficits
A. Discuss pictures of children and grandchildren with the client.
A client with neurocognitive disorder has been admitted to a nursing home. Which nursing intervention will help the client maintain optimal cognitive function? A. Discuss pictures of children and grandchildren with the client. B. Provide the client with a list of tasks to perform each day. C. Watch the evening news on the television with the client. D. Play word games and do crossword puzzles with the client.
C. "Today is January 11th. Tell me about some of the other dances you've been to."
A confused wheelchair-bound client diagnosed with neurocognitive disorder due to Alzheimer disease is homebound. Although she has no contact with men, she says to the home health nurse, "I have a date tonight for the Valentine's dance." What is the most appropriate response by the nurse? A. "I didn't think your spouse was still living. Who is your date with?" B. "You're confused again. There isn't a dance tonight and this isn't Valentine's Day." C. "Today is January 11th. Tell me about some of the other dances you've been to." D. "I think you need some more medication. I'll be right back with your shot."
D. "You're seeing bugs because you are sick, but I don't see any bugs on you."
A delirious client was recently released from soft bilateral wrist and ankle restraints. Suddenly, the client begins to beat the sheets and yell, "Get those bugs away from me! They're all over! Get them!" What is the best initial response by the nurse? A. "Those are just little bugs, they won't hurt you." B. "What kind of bugs are on you?" C. "Just hold very still and the bugs will crawl away." D. "You're seeing bugs because you are sick, but I don't see any bugs on you."
B. Masked by aggressive behaviors
When assessing an adolescent client for depression, it is most important for the nurse to recognize that depression in adolescents is often which of the following? A. Situational and not as serious as depression in adults B. Masked by aggressive behaviors C. An indication of family dysfunction D. Similar in presentation to depression in adult clients
B. Behavior modification
When planning the care of a six-year-old child with oppositional defiant disorder, the psychiatric nurse should include which of the following? A. Cognitive reframing B. Behavior modification C. Reminiscence therapy D. Emotive therapy
B. "I need to spend time with my mother doing something we both enjoy."
A female client diagnosed with mild neurocognitive disorder due to Alzheimer disease is cared for at home by her daughter. Which statement by the daughter indicates to the nurse that she understands personal coping strategies that will be useful in the role of caregiver? A. "I need to postpone my vacation for a few more years." B. "I need to spend time with my mother doing something we both enjoy." C. "I need to stay with my mother 24 hours a day." D. "I need to bathe my mother every day before breakfast."
B. Combativeness C. Auditory hallucinations
A female client is going to be admitted to the geriatric psychiatric unit with a diagnosis of major neurocognitive disorder due to Alzheimer disease. The psychiatric emergency room nurse providing the admission report informs the unit nurse she has behavioral disturbances, primarily aggressive. The admitting nurse should anticipate which of the following? Select all that apply. A. Putting together random words B. Combativeness C. Auditory hallucinations D. Poor concentration E. Refusal to make eye contact
B. "If she brings up the abuse, listen to her and be supportive."
A nursing assistant (NA) asks for advice about talking with a client recently diagnosed with dissociative identity disorder (DID). What would be the nurse's best response when the NA asks, "Should I talk about her childhood abuse?" A. "Ask her to discuss this only with her therapist." B. "If she brings up the abuse, listen to her and be supportive." C. "Remind her that sometimes adults exaggerate their childhood experiences." D. "You will need to really push her to get it all out."
A. Delay seeking treatment for the child's injuries.
A pediatric client has severe injuries to the abdomen. The nurse should suspect child abuse if the parents do which of the following? A. Delay seeking treatment for the child's injuries. B. Give a very detailed description of the events prior to the injuries. C. Exhibit an anxious and concerned attitude. D. Encourage the child to explain the injuries.
B. Atomoxetine C. Amphetamine and dextroamphetamine
A three-year-old client has been diagnosed with attention deficit hyperactivity disorder (ADHD). A friend of the parents old them that the child will likely receive "lots of drugs." The nurse should reply that the child will most likely be prescribed which of the following drugs? Select all that apply. A. Haloperidol B. Atomoxetine C. Amphetamine and dextroamphetamine D. Paroxetine E. Amitriptyline
D. Attend a support group for disaster survivors by day two.
A windstorm severely damaged a client's farm. The client recalls very little about the storm and repeatedly says, "I can't believe the farm is destroyed." Which goal would be most helpful? A. Report decreased depression by day two. B. Apply for job retraining by day two. C. Express anger about his loss by day two. D. Attend a support group for disaster survivors by day two.
B. Diminished pleasure C. Blunted affect D. Difficulty making decisions
When teaching a client about negative symptoms of schizophrenia, which symptoms should the nurse include? Select all that apply. A. Abnormal thoughts B. Diminished pleasure C. Blunted affect D. Difficulty making decisions E. Hallucinations
C. Harsh discipline and inconsistent limit setting
A 13-year-old child is brought to the clinic with a history of conduct disorder. The nursing history reveals several facts about the family. Which parent-related factor is most likely to have contributed to the child's conduct problems? A. Very high expectations of the child B. Excessive involvement in the everyday life of the child C. Harsh discipline and inconsistent limit setting D. Having no other children
B. Physical abuse
A child presents to the nurse's office with stomach aches without any other symptoms for the third time this week. You notice bruises on her arms. When you ask about them she remains silent and avoids eye contact. Which finding would the nurse suspect? A. Autism spectrum disorder B. Physical abuse C. Post-traumatic stress disorder D. Clotting disorder
D. "It works on the serotonin levels in the brain."
A client diagnosed with mild neurocognitive disorder due to vascular disease has comorbid major depressive disorder. He has a flat affect, depressed mood, and short-term memory loss. Paroxetine is prescribed for the depression. A family member says, "I don't remember the reason this medicine might help." What is the nurse's best response? A. "It will increase oxygen levels in the brain." B. "It elevates blood glucose levels in cell of brain" C. "It improves circulation to the brain." D. "It works on the serotonin levels in the brain."
C. Clang associations
A client diagnosed with schizophrenia says, "I want to go home to tome in a dome." When documenting, the nurse will refer to this as which of the following? A. Echopraxia B. Associative looseness C. Clang associations D. Echolalia
B. Thought insertion
A client diagnosed with schizophrenia tells the nurse that another client is "creating negative thoughts in me against my will." The nurse documents that the client is exhibiting which of the following features of schizophrenia? A. Thought blocking B. Thought insertion C. Thought broadcasting D. Thought control
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In order to be admitted to an inpatient treatment program, clients with anorexia nervosa must meet the admission criterion of having experienced at least a 30% weight loss over the immediate past six months. The client currently weighs 84 pounds. The nurse calculates that six months ago, this client weighed at least ________pounds. Record your number rounding to a whole number.
A. "When possible, remain at arm's length from this client."
How should the nurse respond to a mental healthcare worker who asks about the best way to work with a client diagnosed with schizophrenia with paranoid behavior? A. "When possible, remain at arm's length from this client." B. "This client is anxious. Offer back rubs at bedtime." C. "Offer this client a hand-shake before beginning conversation." D. "To get the client's attention, place your hand gently on the arm or hand."
D. "It will regulate a neurotransmitter called serotonin."
The adolescent client is depressed. The client's prescribed medication is fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do inside my brain?" A. "It will raise your level of the brain hormone norepinephrine." B. "It will balance blood glucose and dopamine levels." C. "It will help you feel less depressed." D. "It will regulate a neurotransmitter called serotonin."
C. Donepezil
The client diagnosed with major neurocognitive disorder due to Alzheimer disease is receiving several medications. An unlicensed assistant who is enrolled in nursing school asks the nurse, "Which medication may improve mental functioning by increasing acetylcholine?" Which medication should the nurse identify? A. Trazodone B. Haloperidol C. Donepezil D. Fluoxetine
A. Periodic times of respite from caregiving
The client has a diagnosis of major neurocognitive disorder due to Alzheimer disease and is being cared for by the spouse in the home. What self-care activity will be most important for the nurse to recommend to the spouse? A. Periodic times of respite from caregiving B. Regular attendance at church services C. Participation in reminiscence therapy D. Establishment of a predictable daily schedule
D. Catastrophic reaction
The client has a medical diagnosis of neurocognitive disorder. The nurse observes that when anyone speaks loudly or harshly to the client, the client cries out, retreats to bed, shivers, and covers the head. When documenting and giving intershift report, how should the nurse should refer to the client's behavior? A. Pseudodelirium B. Pseudodementia C. Sundown syndrome D. Catastrophic reaction
A. Blinking or rolling of the eyes
The client has dissociative identity disorder (DID). When the client is changing from one alter to another, which client manifestation should the nurse expect to assess? A. Blinking or rolling of the eyes B. Pallor C. Orthostatic hypotension D. Dystonic reactions
C. Maintaining adequate hydration
The client is experiencing delirium in the postoperative period after open reduction internal fixation of the left hip secondary to a fracture from a fall. What intervention should the nurse address as the highest priority? A. Turning and repositioning every two hours B. Offering frequent reorienting statements C. Maintaining adequate hydration D. Reducing anxiety
D. "It is possible that you were not aware of group time."
The client who has dissociative identity disorder (DID) is now 20 minutes late for cognitive therapy group. The client says, "I was never told to go to that group." What is the nurse's best response? A. "Have you thought about just why you might be resisting treatment?" B. "You can't get out of group that easily." C. "People with dissociative identity disorder forget quite a bit." D. "It is possible that you were not aware of group time."
B. Localized amnesia
The client, although oriented to person, place, and time, cannot remember being extracted from a burning automobile the day before. What term should the nurse use when documenting the client's inability to remember events surrounding the accident? A. Confabulation B. Localized amnesia C. Continuous amnesia D. Suppression
A. Irritable bowel syndrome C. Asthma D. History of headaches
The nurse assessing a client with dissociative identity disorder (DID) expects to note which of the following manifestations? Select all that apply. A. Irritable bowel syndrome B. Intact memory for recent and remote events C. Asthma D. History of headaches E. Elated mood
A. Exposure to a major stressor C. A recent history of being raped
The nurse assessing the client in a fugue state should look for which of the following? Select all that apply. A. Exposure to a major stressor B. Coexisting depression C. A recent history of being raped D. Dissociative episodes E. A history of childhood trauma
A. Act out feelings in a constructive manner.
The nurse employs play therapy with a small group of six-year-old clients. The primary expected outcome is for the clients to do which of the following? A. Act out feelings in a constructive manner. B. Learn how to give and receive feedback. C. Learn to talk openly about themselves. D. Learn problem-solving skills.
D. Inability to cope
The nurse formulates which priority nursing concern for a client experiencing amnesia associated with high levels of anxiety? A. Powerlessness B. Confusion C. Impaired sensory perception D. Inability to cope
C. "I'm a little uneasy about being hypnotized, but it does help release memories."
The nurse has taught a client experiencing dissociative amnesia about therapeutic methods for memory retrieval. The nurse should determine that the instruction has been effective when the client makes which statement? A. "Even if it does uncover hidden memories, I don't want to have electroconvulsive therapy." B. "Anxiety causes this memory problem, and antianxiety agents will greatly reduce it." C. "I'm a little uneasy about being hypnotized, but it does help release memories." D. "If I use relaxation techniques properly, my memories will come back quickly."
B. Confabulation is a means for persons with dementia to make up for their cognitive losses. E. The client's response may be due to her inability to remember an answer.
The nurse is caring for a female client on the inpatient psychiatric unit who has neurocognitive disorder. When the nurse asks who her support persons are, she says her husband takes care of her. Her health record indicates that she has been widowed for six years. The nurse concludes she is confabulating and draws which conclusions? Select all that apply. A. The client is untruthful about her husband. B. Confabulation is a means for persons with dementia to make up for their cognitive losses. C. Disturbed sleep often causes confabulation. D. Confabulation is also known as amnesia. E. The client's response may be due to her inability to remember an answer.
C. "People develop dissociative disorders to protect themselves from extreme anxiety."
The nurse is conducting a client teaching session about dissociative disorders. Which client statement indicates to the nurse an understanding of important concepts about the disorder? A. "Dissociative disorders are caused from past use of hallucinogens." B. "Dissociative disorders serve as a means of avoiding adult responsibilities." C. "People develop dissociative disorders to protect themselves from extreme anxiety." D. "People with dissociative disorder usually have gradual loss of memory for names and phone numbers."
A. Difficulties at school C. Hypersomnia D. Decreased flexibility of affect (flattened affect)
The nurse is conducting a community education session about preventing deaths in adolescents with depression. Which of the following might be considered indicators of depression in adolescents? Select all that apply. A. Difficulties at school B. Excessive washing of hands C. Hypersomnia D. Decreased flexibility of affect (flattened affect) E. Acquired immunodeficiency syndrome (AIDS)
D. Binging and purging
The nurse is conducting an in-service education session about the relationship between anxiety and bulimia nervosa. The nurse best describes the relationship by stating when a client has bulimia nervosa, an increase in the anxiety level will generally result in which of the following? A. Rigidly controlling what he or she eats B. Consuming alcohol C. Overeating D. Binging and purging
C. The client shows the nurse a completed food and emotion diary.
The nurse is evaluating the progress of an adolescent bulimic client who is being treated as an outpatient. Which client behavior would indicate that the client is making positive progress? A. The client asks the nurse many details about the nutritional content of foods. B. The client describes eating at times other than when the family members eat. C. The client shows the nurse a completed food and emotion diary. D. The client reports enjoying spending time alone after meals.
C. Indifference to being held or hugged
The nurse is providing community education about autism to a group of parents. The nurse concludes that teaching has been effective if the parents describe which of the following as common behavioral signs of autism? A. Highly creative, imaginative play B. Overly affectionate behavior toward parents C. Indifference to being held or hugged D. Early development of language
D. Give the client ample time to perform the ADLs as independently as possible.
The nurse is teaching a family caregiver how to help a family member with early-stage neurocognitive disorder due to Alzheimer disease complete activities of daily living. Which information should be included in the teaching? A. Perform ADLs for the client. B. Tell the client that the ADLs must be finished by 9:00 a.m. C. Have the client plan a schedule for ADLs. D. Give the client ample time to perform the ADLs as independently as possible.
A. Mainly in young girls who perceive themselves to be grossly overweight
The nurse is teaching a group of young adolescents about eating disorders. The nurse would consider the sessions effective if the participants state that anorexia nervosa is best defined as an eating disorder that occurs in which individuals? A. Mainly in young girls who perceive themselves to be grossly overweight B. Only in young girls who are depressed C. Primarily in young girls who live in chaotic families D. In young boys and girls alike
C. Uncontrollable motions in the body
The nurse is to complete an AIMS assessment of the client. When explaining this test to the client, the nurse should say that this test will help to identify if the client is beginning to have which of the following? A. Weak muscles B. Shaking hands and feet C. Uncontrollable motions in the body D. Slowed body movement
E. Reduce proximity to others.
The nurse observes that the client with schizophrenia appears very preoccupied. The client is pacing back and forth in the hall, periodically looking to the side, clenching the fist, and saying, "I told you to go away." The nurse should plan to take which actions during client care? Select all that apply. A. Avoid touching the client during conversation. B. Reassure the client of the safety of the environment. C. Offer frequent orienting stimuli. D. Refrain from using nonverbal hand gestures. E. Reduce proximity to others.
C. "Focus on what I can see and hear externally."
The nurse should conclude that client education to manage dissociative episodes is effective if the client states to do which of the following if he starts to dissociate? A. "Begin my relaxation technique." B. "Immediately take my antianxiety medication." C. "Focus on what I can see and hear externally." D. "Focus on my internal feelings."
D. Creation of a calm, safe environment
The nurse should prioritize which nursing intervention for a client recently admitted to an inpatient unit with a dissociative disorder? A. Working through past trauma B. Promoting social skills C. Increasing sensory stimulation D. Creation of a calm, safe environment
D. Posttraumatic stress syndrome E. Anxiety
The nurse should select which nursing concerns as appropriate priorities for a client experiencing a fugue state? Select all that apply. A. Disruption of family processes B. Impaired self-esteem C. Relocation-related stress D. Posttraumatic stress syndrome E. Anxiety
A. "The idea of eating makes me nauseated." B. "I want to be a chef and cook for other people." C. "People say I'm skinny, but I'm fat and repulsive." D. "I don't have periods anymore. I'm glad."
The school nurse is conducting an assessment to determine if a client has anorexia nervosa. Which statement(s) by the client will most suggest that the client may have this disorder? Select all that apply. A. "The idea of eating makes me nauseated." B. "I want to be a chef and cook for other people." C. "People say I'm skinny, but I'm fat and repulsive." D. "I don't have periods anymore. I'm glad." E. "I know that I have a problem with eating."
C. Enuresis
The school nurse is planning a community education program about childhood mental health problems that appear to be genetically transmitted. While conducting the program, the nurse will emphasize information about which problem? A. Anxiety states B. Oppositional defiance disorder C. Enuresis D. Sleepwalking
B. Separation anxiety disorder
The school nurse is teaching parents of six- and seven-year-old students about anxiety disorders in early school-age children. Which disorder should the nurse emphasize in the discussion? A. Obsessive-compulsive disorder B. Separation anxiety disorder C. Posttraumatic stress disorder (PTSD) D. Depression
C. Brain dysfunction or disease
The spouse of a client who scores 11 out of 30 on the Mini-Mental State Examination asks the nurse what this score might mean. The nurse's response should convey that this score suggests a high likelihood of which of the following? A. Bipolar disease B. Educational deficiencies C. Brain dysfunction or disease D. Low self-esteem
A. Body weight
What is a priority nursing assessment before the administration of the first dose of olanzepine? A. Body weight B. History of indigestion C. Usual sleep pattern D. Food and fluid preferences
C. Impaired social interactions
What is a priority nursing concern for a client diagnosed with schizophrenia with residual features? A. Anxiety B. Interrupted communication C. Impaired social interactions D. Inability to perform self-care
A. "Blurred vision is a side effect of your medication that usually resolves within a few weeks."
What is the best response by the nurse to a client who reports blurred vision that began after beginning a traditional antipsychotic? A. "Blurred vision is a side effect of your medication that usually resolves within a few weeks." B. "You need to schedule an appointment with your eye doctor to get a new prescription for your eyeglasses." C. "Blurred vision is a permanent condition as a result of your medication." D. "You need to stop taking your antipsychotic medication and notify your healthcare provider immediately."
C. Ask if the client see something on the wall.
What is the most appropriate nursing intervention for a client diagnosed with schizophrenia who looks away from the nurse and stares at the wall while making a facial grimace? A. Redirect the conversation to a neutral topic. B. Administer the prescribed prn trihexyphenidyl. C. Ask if the client see something on the wall. D. End the conversation because the client is not listening.
D. "That must be a frightening thought. We are nurses who work at this hospital."
What is the most appropriate response by the nurse to a client diagnosed with schizophrenia who refuses to be weighed by a member of the nursing staff and says, "Everyone here is part of the secret police and wants to torture me"? A. "There is no need to be frightened. We will keep you safe from torture." B. "That is a strange idea. We aren't secret police persons." C. "Being suspicious isn't easy, is it? You won't be tortured here." D. "That must be a frightening thought. We are nurses who work at this hospital."
C. "The exact cause of schizophrenia is unclear at this time."
What is the nurse's best response to a family member of a patient diagnosed with schizophrenia who asks the nurse to explain what causes this disorder? A. "It is likely that poor parenting skills cause schizophrenia to occur." B. "It is clear that early-age psychological traumas cause schizophrenia." C. "The exact cause of schizophrenia is unclear at this time." D. "Research indicates that schizophrenia is caused by a genetic predisposition."
C. "Your spouse will probably have no memory of events during the fugue."
What is the nurse's best response? A. "Avoid mentioning it, or your spouse may start alternating old and new identities." B. "It is not possible to predict whether your spouse will remember the fugue state." C. "Your spouse will probably have no memory of events during the fugue." D. "Your spouse will be able to tell you —if you can gently encourage talking."
C. Attend one group meeting accompanied by a staff member within three days.
What short-term goal should the nurse formulate as an appropriate goal for a hospitalized client who is severely withdrawn? A. Be more comfortable in group situations by three days. B. Enjoy participating in group therapy by the time of discharge. C. Attend one group meeting accompanied by a staff member within three days. D. Voluntarily lead the unit community meeting by the time of discharge from the hospital.
A. "Haloperidol improves your thinking and valproic acid stabilizes your moods."
What should be the nurse's best response to a client diagnosed with schizoaffective disorder who asks for an explanation of the action of the prescribed haloperidol and valproic acid? A. "Haloperidol improves your thinking and valproic acid stabilizes your moods." B. "Haloperidol makes your moods calmer and valproic acid prevents tight muscles." C. "This combination is good for people who have problems like yours." D. "This is an old combination of drugs that helps people to keep thinking and feelings in balance."
B. Begin preparing the client for immediate transfer to an emergency department.
What should the nurse do next for a client who recently began taking a typical antipsychotic medication and is experiencing general body rigidity, diaphoresis, body temperature of 39.4°C (103°F), and a pulse of 130 beats per minutes? A. Arrange for an additional healthcare provider's visit later in the day. B. Begin preparing the client for immediate transfer to an emergency department. C. Administer the prescribed prn anticholinergic medication. D. Assess the client for indications of orthostatic hypotension.
D. Akathisia
What term should the nurse use to document a client who is taking antipsychotic medications, pacing the hallway, unable to remain still, and reports feeling nervous? A. Dystonia B. Tardive dyskinesia C. Akinesia D. Akathisia
B. Client remains in a safe and secure environment to prevent injury.
When working with a client who has neurocognitive disorder, the primary intervention by the nurse should be to ensure which of the following? A. Client discusses feelings of fear and loss to prevent low self-esteem and anxiety. B. Client remains in a safe and secure environment to prevent injury. C. Client is offered dietary choices to stimulate appetite. D. Client meets other clients with neurocognitive disorder to prevent social isolation.
A. Waxy flexibility C. Extreme psychomotor retardation E. Rigidity
Which manifestations should the nurse anticipate in a client who is diagnosed with schizophrenia and demonstrates catatonic behavior? Select all that apply. A. Waxy flexibility B. Paresthesias C. Extreme psychomotor retardation D. High blood pressure E. Rigidity
D. Put traditional seasonal decorations within the client's view.
Which nursing intervention would be most effective in improving the orientation level of a 74-year-old male client with mild neurocognitive disorder? A. Keep the client's television tuned to a 24-hour news station during the daytime hours. B. Assure the client that his deceased spouse is expected home later in the day. C. Speak directly into the client's ear when telling him the day of the month and time. D. Put traditional seasonal decorations within the client's view.
A. Decrease fear and anxiety.
Which of the following is the highest priority intervention for the nurse who is working with a child with a phobia? A. Decrease fear and anxiety. B. Have the child face his or her fear. C. Allow the child to express fears. D. Protect the child from fears.
D. Indications of any sort of infection
Which of the following manifestations should the nurse teach a client to report to the healthcare provider immediately while taking clozapine? A. Feelings of increased energy and interest in the environment B. Unusual reactions to exposures to the sun C. Interferences with the normal sleep pattern D. Indications of any sort of infection
C. Limit setting and consistency
Which primary interventions should the nurse plan for when a child has conduct disorder and is impulsive and aggressive? A. Assertiveness training B. Open communication and a flexible approach C. Limit setting and consistency D. Open expression of feelings
D. Risk for violence inflicted toward self or others
Which priority nursing concern should be given highest priority for a client admitted to an acute care psychiatric hospital unit and diagnosed with schizophrenia who exhibits paranoia? A. Inadequate communication B. Impaired social relationships C. Alterations in thought processes D. Risk for violence inflicted toward self or others
A. "We went to a musical concert, and he smiled and applauded the musicians." D. "For the past week, he has gotten up, dressed, and taken a walk early each morning."
Which statements by the family member of a client diagnosed with chronic schizophrenia should indicate to the nurse that the client is experiencing a reduction in negative symptoms? Select all that apply. A. "We went to a musical concert, and he smiled and applauded the musicians." B. "I've noticed that his thoughts are better organized." C. "It's been more than a month since he said that he is a Martian prince." D. "For the past week, he has gotten up, dressed, and taken a walk early each morning." E. "We walked together for 15 minutes, and I could see no evidence he was 'hearing voices.'"
