RNSG 1533 - Cognition & Coping
Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? The home environment... 1. maintains loose personal boundaries. 2. places an overemphasis on food. 3. is overprotective and demands perfection. 4. condones corporal punishment.
Answer 3 The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors? A. Plan the client's schedule to allow time to perform rituals B. Verbalize disapproval of ritualist behaviors C. Place the client in protective isolation D. Increase stimuli in the client's immediate surroundings
Answer A
A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following statements should the nurse make: A. "It is best to discontinue the medication slowly over 1 or 2 months." B. "If the medication hasn't helped you in three months, it's not going to." C. "You will likely gain weight if you stop taking the medication." D. "This medication is the only treatment available for your condition."
Answer A
Which level of anxiety helps the client focus attentionto learn, problem solve, think, act, feel, and protect himself? A. mild B. .moderate C. Severe C. panic
Answer A In mild anxiety sensory stimulation increases and helps the person focus attention to learn, solve problems, and think. Moderate anxiety causes the person to have difficulty concentration independently but he or she can be redirected to the topic
Which of the following is inconsistent with panic-level anxiety? A. this level of anxiety can be sustained indefinitely B. the nurse needs to maintain a non stimulating environment C. the nurse should remain with the client until the panic recedes D. the goal is to lower the clients anxiety to mild or moderate before proceeding with anything else
Answer A Panic-level anxiety cannot be sustained indefinitely. The nurse should remain with the client until the panic recedes and maintain a non stimulating environment. The goal is to lower the client's anxiety to mild or moderate before proceeding with anything else Panic-level anxiety cannot be sustained indefinitely. The nurse should remain with the client until the panic recedes and maintain a non stimulating environment. The goal is to lower the client's anxiety to mild or moderate before proceeding with anything else
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 client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Support Group C. Private counseling D. Vocational rehabilitation services
Answer A Rationale: Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approac assists clients in managing illness so inpatient hospitalizations can be avoided.
A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply) A. Encouraging the client to recognize the signs of escalating anxiety. B. avoid any situation that causes stress. C. employ newly learned relaxation techniques. D. cognitively reframe thoughts about situations that generate anxiety. E. avoid caffeinated products. F. take as much medicine as needed.
Answer A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.
A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply) A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability F. Euphoria
Answer A, D, and E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.
A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first? A. Administer PRN medication for agitation B. Attempt to reduce environmental stimuli C. Request a prescription for physical restraints D. Place the client in seclusion
Answer B
A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. Which of the following dietary items should the nurse instruct the client to avoid? A. Peppermint candy B. Pure vanilla extract C. Salt D. Chocolate
Answer B
A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? A. "You can take this medication when needed." B. "The medication takes a few weeks to build up in your system." C. "You should plan to take this medication for 6 months." D. "Relapsing after withdrawing from this medication is rare."
Answer B
When traveling alone and away from home, a client experiences trembling and palpitations. These symptoms have impeded the client from leaving her home. The nurse would correctly note that these are symptoms of which type of phobia? A. OCD B. Agoraphobia C. Compulsion D. Obsession
Answer B Agoraphobia : occurs when the client travels away from home and experiences anxiety, with symptoms such as palpitations and trembling
A client is diagnosed with OCD. Which of the following should be included in the plan of care for this client? A. setting strict limits on compulsive behavior B. giving the client time to perform rituals C. preventing ritualistic behavior D. Increasing environmental stimulation
Answer B Giving the client time to perform rituals: the nurse should give the client time to perform rituals b/c this reduces anxiety. The other options would increase the client's anxiety.
A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has injuries that indicate physical abuse. When preparing to interview the parent, which of the following actions should the nurse plan to take? A. Insist that the parent tell the nurse how the child was injured B. Tell the parent that a child protective agency must be notified C. Show disapproval to the parent regarding the infant's condition D. Call at least 2 other staff members to sit in the room during the interview
Answer B Rationale: The nurse should tell the parent that a state protective agency must be notified of the infant's condition and explain the process to the parent.
A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, "Back off. Leave me alone." Which of the following statements should the nurse make? A. "I demand that you calm down now. Your behavior is unacceptable." B. "I will close the door to provide privacy, and you can tell me what is bothering you." C. "I will give you space if you calm down. Tell me what is causing you to feel so tense." D. "I will leave you alone for a few minutes while you try to control yourself."
Answer C
A nurse is caring for a client who has bipolar disorder and has been prescribed lithium. The client's adult child states, "I'm upset that my father is taking this medication." Which of the following responses should the nurse make: A. "It will be alright because your father's provider knows what to do." B. "You should be more concerned about your father's mania, which puts him at risk for injury." C. "Tell me what worries you have about your father taking this medication." D. "This is an important medication to treat your father's condition."
Answer C
A nurse on an acute mental health unit is assessing a client with obsessive-compulsive disorder (OCD). Which of the following behaviors should the nurse expect? A. Being intentionally dishonest B. Jumping rapidly between topics of conversation C. Tapping the 4 sides of a light switch D. Mimicking the movements of another person
Answer C
A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? A. Tell the client that the nurse will talk to him at his request B. Allow the client to skip group activities if he chooses C. Leave the client alone for frequent rest periods throughout the day D. Build trust with the client by sitting quietly with him.
Answer D
A nurse in an acute mental health facility is leading a nursing discussion about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include? A. A client who is involuntarily admitted must take prescribed medications B. An involuntary admission of a client is limited to 2 weeks C. A client who is involuntarily admitted can leave the facility against medical advice D. An involuntary admission is justified if the client is a danger to others
Answer D Rationale: A client who is a danger to self or to others qualifies for an involuntary admission. The inability to meet basic needs due to the need for mental health treatment is also justification for an involuntary admission.
The nurse is assessing a client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is A. skin rash B. Sedation C. Vertigo D. diarrhea
Answer D Diarrhea
A nurse is providing discharge teaching to the parent of an adolescent client who has bulimia nervosa and has been hospitalized for several weeks. Which of the following statements should the nurse identify as an indication that the parent understands the teaching? A. I should allow my child to make independent decisions B. I should give my child a laxative every morning C. I should make sure my child takes antipsychotic medication several times daily D. I should discourage my child from exercising
Answer: A. I should allow my child to make independent decisions
A nurse is teaching a client who has SAD about the use of light therapy. Which of the following statements should the nurse make? A. Light therapy suppresses the natural nighttime release of melatonin B. You should plan your light therapy session before going to bed C. You should begin with 2-min therapy sessions and progress to 10-min therapy sessions D. Light therapy is less effective than medications in treating SAD
Answer: A. Light therapy suppresses the natural nighttime release of melatonin
A nurse is assessing a newly admitted client who has GAD and states "I drink alcohol to forget the pain". The client is exhibiting a maladaptive response to which of the following defense mechanisms? A. compensation B. conversion C. projection D. suppression
Answer: A. compensation
A nurse is teaching a client who has anxiety and a new prescription for buspirone. Which of the following pieces of information should the nurse include in the teaching? A. buspirone carries a high potential for abuse B. avoid consuming grapefruit juice when taking this medication C. take medication 4x daily D. peak effects of buspirone occur within 1 week
Answer: B Rationale: Grapefruit juice can cause levels of the medication to increase. It can also cause drowsiness, and subjective effects such as dysphoria.
A nurse is providing teaching for a client who has a new prescription for buspirone. Which of the following statements indicates an understanding of the teaching? A. watch for signs of dehydration B. monitor kidney function C. take on an empty stomach D. may take several weeks to notice the effects
Answer: D. Rationale: Buspirone may take several weeks to notice effects. Buspirone is an anxiolytic- initial response is a week, and peak response takes several weeks (should not be given PRN for anxiety)
A nurse at an acute care facility is caring for a client receiving IV antibiotic treatments for an infection. The client reports daily alcohol use at home. On the second day of admission, the client becomes agitated and has BP of 195/102 and HR of 118/min. Which of the following actions should the nurse plan to take? A. administer methadone when agitation increases B. administer zolpidem before meals C. request prescription for a different antibiotic D. request prescription for chlordiazepoxide
Answer: D. request prescription for chlordiazepoxide Rationale: Chlordiazepoxide is med for alcohol withdrawal
A nurse is reviewing lab reports for a client who is taking risperidone. The nurse should identify that which of the following results indicates a potential adverse reaction to the medication? A. elevated blood glucose B. elevated WBC C. decreased platelet count D. decreased AST
Answer: Elevated blood glucose Rationale: Risperidone is a second-generation antipsychotic- can cause diabetes, weight gain, and dislipidemia.
A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? a. "Attending group therapy, even if you're tired, is an important part of your treatment." b. "That's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." c. "It is normal to feel tired when you're feeling depressed. The others in group therapy also feel this way." d. "I agree with your decision to wait for participation in group therapy until you begin to feel better."
Answer: a. "Attending group therapy, even if you're tired, is an important part of your treatment." Rationale: The nurse provides a therapeutic response by giving the client information to make an informed decision. Group therapy is beneficial to the client who has depression by promoting peer support and reducing social isolation.
A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? a. "I pick my face when I am nervous" b. "I have bald patched from pulling out my hair" c. "I inspect my body in the mirror several times a day" d. "I am unable to part with any of my belongings"
Answer: a. "I pick my face when I am nervous"
A nurse is providing teaching to a new client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make? a. "feelings of sedation should resolve in about 1 week" b. "there is no risk of physical dependence with this medication" c. "you can increase the dose when you feel especially anxious" d. "it will take several months for you to feel the maximum benefit of the medication"
Answer: a. "feelings of sedation should resolve in about 1 week" Rationale: Diazepam = benzodiazepine. Sedation and psychomotor slowing should subside in 7-10 days-Are at risk for dependence-NOT to increase dose w/o approval of provider-immediate onset of action
A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? a. "yesterday my partner put on a jacket upside down" b. "my partner has trouble reading the newspaper" c. "my partner often repeats words" d. "last week, my partner did not recognize the sound of the alarm clock"
Answer: a. "yesterday my partner put on a jacket upside down" Rationale: apraxia = lack of ability to accomplish once-known tasks
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching? a. "you should have your WBC count checked once per week for 6 months" b. "you should check yourself every 3 days for weight loss" c. "you might experience frequent loose stools" d. "you might experience ringing in your ears"
Answer: a. "you should have your WBC count checked once per week for 6 months" Rationale: antipsychotic, can cause agranulocytosisIncorrect answers: -causes weight gain, not weight loss-constipation-tinnitus not an adverse effect of clozapine
A nurse is caring for a client who is undergoing ECT. Following the procedure, which of the following actions should the nurse take? a. administer oxygen b. administer an anticonvulsant c. administer an opioid antagonist d. administer IV fluids
Answer: a. administer oxygen Rationale: In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable
A nurse is caring for a client who has an alcohol use disorder and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time? a. administer substitution therapy medications b. teach the client the physical symptoms of withdrawal c. provide the client with information about a 12-step program d. identify the causes of the client's alcohol disorder
Answer: a. administer substitution therapy medications Incorrect answers: education following acute stage of alcohol use disorder
A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? a. elevated BP b. weight gain c. muscle twitching d. 2+ peripheral edema
Answer: a. elevated BP Rationale: phenelzine is a MAOI, increased BP increases risk of hypertensive crisis
A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms? a. repression b. splitting c. conversion d. projection
Answer: a. repression *unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness
A nurse on an acute care unit is providing post-op care to an older adult client who develops delirium. Which of the following actions should the nurse take? a. request a prescription for an antianxiety medication b. provide the client with a stimulating activity prior to bedtime c. dim the lights in the client's room at night d. encourage the client to make decisions about her daily routine
Answer: a. request a prescription for an antianxiety medication
A nurse on a rehab unit is providing teaching to the partner of a client who is experiencing stimulant withdrawal. Which of the following statements by the partner indicates an understanding of the teaching? a. "increased energy is a sign of withdrawal" b. "depression is a manifestation of withdrawal" c. "decreased appetite is a manifestation of withdrawal" d. "delirium tremens can occur during withdrawal"
Answer: b. "depression is a manifestation of withdrawal" Rationale: depression and suicidal thoughts are most serious adverse effects of stimulant withdrawal
A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds, "Yes, several members of my church choir came to see me." The nurse knows that only the client's daughter visited the day before. Which of the following cognitive impairments is the client demonstrating? a. perseveration b. confabulation c. apraxia d. agnosia
Answer: b. confabulation Rationale: Filling in gaps in memory by fabrication. Client unconsciously makes up responses that are inaccurate to avoid the embarrassment of memory loss
A nurse caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room. The client begins yelling "I've received terrible care here, and no one bothers to help me" The nurse should recognize that the client is demonstrating which of the following defense mechanisms? a. denial b. displacement c. reaction formation d. projection
Answer: b. displacement Rationale: redirection of thoughts/ feelings from an object that causes anxiety to a safer, more acceptable one(Projection occurs when the client attributes undesired impulses to another person)
A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client? a. seizures b. dizziness c. polyuria d. insomnia
Answer: b. dizziness Rationale: Dizziness, drowsiness, and sedation are common adverse effects of benzodiazepines
A nurse is updating the plan of care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? a. hypertension b. drowsiness c. panic attacks d. diarrhea
Answer: b. drowsiness Rationale: drowsiness is an expected side effect of amitriptyline and other TCAs. sedation is most likely to be present during the first few weeks of treatment and can increase risk of falls. Incorrect answers:-OH is common (not hypertension)-suicidal thoughts is common (not panic attacks)-anticholinergic effects = constipation not diarrhea
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam? a. decreased pulse rate b. increased BP c. decreased urinary output d. increased nausea
Answer: b. increased BP Rationale: Lorazepam is a benzodiazepine that is given to a client who is experiencing alcohol withdrawal for stabilizing vital signs, preventing seizures, and treating delirium tremens.
Which of the following findings should the nurse expect during alcohol withdrawal? a. low body temp b. insomnia c. muscle flaccidity d. bradycardia
Answer: b. insomnia Rationale: insomnia and restlessness-elevated temp-muscle tremors-tachycardia
A home health nurse is providing teaching for the family of a client who has moderate Alzheimer's disease. The family plans to care for the client in the home. Which of the following recommendations should the nurse include in the teaching? a. place nonskid throw rugs over smooth floors b. install locks at the tops of exterior doors c. provide clothing that has zippers instead of buttons d. encourage the client to take frequent naps during the day
Answer: b. install locks at the tops of exterior doors Rationale: will decrease risk for wandering and getting lost- client w/ moderate Alzheimer's disease loses the ability to reach and look upward
A nurse is planning care for a client who has completed detoxification from opioid use disorder. The nurse should plan to teach about which of the following medications? a. methadone b. naltrexone c. buprenorphine d. disulfiram
Answer: b. naltrexone Rationale: opioid antagonist used for the long-term maintenance of opioid use disorder. It is the usual med of choice following detox from opioids(Methadone is an opioid agonist that is prescribed as a substitute for opioids prior to detox)
An ER 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'm having a heart attack!" The nurse should determine the client's level of anxiety to be: a. moderate b. panic c. severe d. mild
Answer: b. panic
A nurse is caring for a client who has Alzheimer's disease. The client's son states the client has begun wandering away from her home. Which of the following responses should the nurse offer? a. you should plan to move your mother into a home soon b. place a complex lock at the top of each door that leads outside c. it is time to place your mother in a LTC facility d. have you reminded your mother about the dangers of wandering away from home?
Answer: b. place a complex lock at the top of each door that leads outside
A nurse is caring for a client who has acute delirium. Which of the following findings should the nurse expect? a. progressive deterioration of cognitive function b. rapid fluctuation in LOC c. loss of language ability d. absence of contributing factors to pinpoint the cause of delirium
Answer: b. rapid fluctuation in LOC Rationale: Incorrect answers:-progressive deterioration of cognitive function, loss of language = dementia
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following clinical manifestations should the nurse expect? a. sedation b. rhinorrhea c. bradycardia d. hypothermia
Answer: b. rhinorrhea (runny nose) Rationale: flu-like symptoms- yawning, sneezing, abdominal pain
A nurse is providing teaching to a client who has panic disorder and a new prescription for clomipramine. Which of the following adverse effects should the nurse include in the teaching? a. diarrhea b. sedation c. hypertension d. urinary frequency
Answer: b. sedation Rationale: Adverse effects of Clomipramine (TCA) include sedation, orthostatic hypotension, anticholinergic effects
A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects? a. increased intracranial pressure b. serotonin syndrome c. acute kidney injury d. hypertensive crisis
Answer: b. serotonin syndrome Rationale: tranylcypromine is a MAOI and sertraline is a SSRI
A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? a. you can take this medication when needed b. the medication takes a few weeks to build up in your system c. you should plan to take this medication for 6 months d. relapsing after withdrawing from this medication is rare
Answer: b. the medication takes a few weeks to build up in your system Rationale: Paroxetine is a SSRI- takes about 4 weeks for initial effects to develop, optimal effects seen in 8-12 weeks Incorrect answers:-should not be taken PRN-treatment should continue for at least 1 year-withdrawal frequently results in relapse of anxiety disorder
A nurse is providing teaching to a client who has a new prescription for diazepam. Which of the following instructions should the nurse include in the teaching? a. expect this medication to make you anxious b. this medication can be habit-forming c. take this medication on an empty stomach d. this medication needs to be taken for 2-3 weeks to reach the full therapeutic effect
Answer: b. this medication can be habit-forming Rationale: diazepam is a benzodiazepine, can cause physical dependence/ are controlled substancesIncorrect answers:-take w/ food-benzos take effect immediately
A nurse is providing discharge teaching for a client who has a new prescription for doxepin (antidepressant). Which of the following adverse effects is associated with this medication? a. weight loss b. diarrhea c. drowsiness d. bradycardia
Answer: c. drowsiness
A nurse is reviewing the medical record of a client who has a new prescritiption for benzodiazepine. For which of the following findings should the nurse question the provider's prescription? a. skeletal muscle injury b. history of status epilepticus c. hypotension d. insomnia
Answer: c. hypotension Rationale: benzos can cause severe hypotension and increase the client's risk of cardiac arrest
A nurse in an acute mental health facility is planning care for a client who has OCD. Which of the following actions should the nurse include in the plan? a. encourage the client to focus on personal hygiene b. limit the hours the client sleeps each day c. instruct the client to practice thought stopping d. make negative statements about the client's behavior
Answer: c. instruct the client to practice thought stopping Rationale: The nurse should teach the client who has OCD to use thought stopping. By saying, "stop" out loud, the pt can learn to interrupt obsessive thoughts
A nurse is teaching a client who has a prescription for a tricyclic antidepressant. Which of the following instructions should the nurse include in the teaching? a. take medication within 1 hour of waking each morning b. limit alcohol to 2 drinks per week c. it can take 6 weeks to achieve the full therapeutic effect of this medication d. stop taking the medication if you experience dizziness
Answer: c. it can take 6 weeks to achieve the full therapeutic effect of this medication Rationale: it can take 6-8 weeks to achieve full therapeutic effect of TCAs Incorrect answers:-take TCA at bedtime to decrease sleepiness during the day-avoid drinking ANY alcohol, it will block therapeutic effects-TCA can cause dizziness, but this adverse effect is expected to diminish after the first few weeks
A nurse is developing a plan of care for a client who has anorexia nervosa. The nurse should identify that which of the following actions is contraindicated for this client? a. Explaining that tube feedings are necessary if the client refuses oral intake b. weighing the client each day prior to any oral intake c. permitting the client to spend some quiet time alone after each meal d. refraining from commenting about the client's eating during meal times
Answer: c. permitting the client to spend some quiet time alone after each meal Rationale: The nurse should directly observe the client for a minimum of 1 hour following meals. This intervention prevents the client from purging or discarding hidden food. Therefore, permitting the client to have alone time following meals is contraindicated for his plan of care.
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome? a. flat affect b. refusal to accept help from others c. report of intense guilt d. denial of the sexual assault
Answer: c. report of intense guilt Rationale: other findings of rape-trauma syndrome are mood swings/ intense emotions, dependence on others
A nurse on an inpatient rehab unit is assessing a client who has a history of opioid use and is experiencing withdrawal. Which of the following manifestations should the nurse expect? a. hyperactivity b. headache c. rhinorrhea d. tremulousness
Answer: c. rhinorrhea Also expect:-lacrimation-pupillary dilation-yawning-piloerection
A nurse is caring for a client who is having an acute panic attack. Which of the following actions should the nurse take? a. speak to the client in a raised voice b. walk the client to the dayroom c. use repetition when speaking with the client d. secure the client in his room alone
Answer: c. use repetition when speaking with the client Rationale: When having a panic attack, the client may have a hard time understanding what the nurse is saying. Simple phrases and repetition are effective methods of communication
A nurse is assessing a client who is taking buspirone to treat GAD. Which of the following findings should the nurse identify as an adverse effect of this medication? a. arthralgia b. photophobia c. xerostomia d. bradycardia
Answer: c. xerostomia Rationale: Buspirone is a benzodiazepine- can cause xerostomia, headaches, nausea, and insomnia
A nurse is talking with the partner of a client who has alcohol use disorder. Which of the following statements by the client's partner should the nurse identify as an indication of codependence? a. "My partner is addicted to both alcohol and cocaine" b. "I have an alcohol problem just like my partner does" c. "My partner only drinks to deal with her major depression" d. "I call my partner's boss when she's drunk and can't go to work"
Answer: d. "I call my partner's boss when she's drunk and can't go to work" Rationale: Codependent individual takes on extra responsibilities and assists the client who has alcohol use disorder in meeting obligations- affects individual's self-worth and can cause the individual to put the needs of the client first
A nurse is providing teaching to a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make? a. "you will get very sick if you drink alcohol while taking this medication" b. "the medication will be administered as a SQ injection" c. "you should take this medication on an empty stomach" d. "the medication might cause you to have episodes of diarrhea"
Answer: d. "the medication might cause you to have episodes of diarrhea" Rationale: this is an adverse effect of acamprosate.This does NOT function as aversion therapy, instead reduces the unpleasant feelings associated w/ abstinence such as anxiety, dysphoria, and tension
A nurse is assessing a client who has a binge-eating disorder. Which of the following findings should the nurse expect? a. amenorrhea b. abdominal pain c. restricted calorie intake d. frequent use of laxatives
Answer: d. abdominal pain Rationale: The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating excessive volumes of food.
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? a. monitor the client's liver function while taking this medicaton b. increase the dosage of this medication every 72 hours c. offer the client a PRN NSAID while taking this medication d. administer the medication at bedtime
Answer: d. administer the medication at bedtime Rationale: Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this medication at bedtime to reduce the risk for injury due to bradycardia and syncope.
A nurse is providing teaching to a client who has a new prescription for buspirone to treat anxiety. Which of the following statements should the nurse include in the teaching? a. use buspirone w/ caution b/c it raises risk of suicidal thoughts b. you can minimize adverse effects by taking buspirone with grapefruit juice c. buspirone enhances the depressant effects of alcohol d. buspirone cause nausea in some people
Answer: d. buspirone cause nausea in some people Rationale: Buspirone is a anxiolytic. Can cause nausea
A nurse is providing teaching to a client about cannabis use disorder. Which of the following statements indicates an understanding of the teaching? a. "withdrawal of cannabis occurs 3 days after cessation" b. "there are no physical manifestations of withdrawal from cannabis" c. "drug screens can detect cannabis for up to 8 weeks after use" d. cannabis use can produce effects resembling the effects of alcohol use"
Answer: d. cannabis use can produce effects resembling the effects of alcohol use" Rationale: also a CNS depressant-physical manifestations of withdrawal include abdominal pain, shakiness, sweating, fever, chills, headaches-cannabis can be detected in drug screens for up to 4 weeks
A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? a. client requires assistance with eating b. client independently manages personal finances c. client has bladder incontinence d. client is able to identify the names of family members
Answer: d. client is able to identify the names of family members Rationale: clients w/ AD maintain this ability until stage 6(incontinence also stage 6, requiring assistance eating is stage 7)
A nurse is caring for a client with alcohol use disorder who has undergone detox. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety? a. varenicline b. clonidine c. buprenorphine d. disulfiram
Answer: d. disulfiram Rationale: aversion therapyIncorrect answers:a. varenicline- reduces nicotine cravings b. clonidine- heroin withdrawalc. buprenorphine- treats opioid withdrawal
A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? a. obtain a PRN prescription for restraints from the client's provider b. visually observe the client every 10 mins until restraints are removed c. ensure 3 fingers can fit between the restraint and the client's wrist d. document the client's behavior every 15 min while restraints are in place
Answer: d. document the client's behavior every 15 min while restraints are in place Rationale: prescription needed, CANNOT be PRN though-one-on-one observation needed for restraints-2 fingers, not 3
A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? a. bradycardia b. increased somnolence c. slurred speech d. headache
Answer: d. headache Rationale: other findings include hand tremors, nausea, vomiting, sweating, depression, or irritability
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse prepare to administer? a. carbamazepine b. clonidine c. propranolol d. lorazepam
Answer: d. lorazepam Rationale: benzodiazepine- first treatment for alcohol withdrawalIncorrect answers:can be used WITH benzodiazepine for AWS, but not the first choice for treatment
A nurse is assessing a client who is experiencing PTSD following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? a. bupropion b. phenelzine c. mirtazapine d. paroxetine
Answer: d. paroxetine Rationale: SSRI, first-line treatment for PTSDIncorrect answers:-Buproprion = antidepressant for smoking cessation, depression, ADHD-Phenelzine = MAOI, can be prescribed for PTSD but not first-line-Mirtazapine = TCA, also can be used for PTSD but not first-line
A nurse in an acute mental health facility is reviewing the medication records of a group of patients. The nurse should expect a prescription for mematine for a client who has which of the following diagnoses? a. postpartum depression b. schizophrenia c. obesity d. severe Alzheimer's disease
Answer: d. severe Alzheimer's disease Rationale: Memantine, NMDA receptor agonist, slows progression of manifestations and improves cognitive function
A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? a. postpartum depression b. schizophrenia c. obesity d. severe Alzheimer's disease
Answer: d. severe Alzheimer's disease Rationale: The nurse should expect a prescription for memantine for a client who has moderate to severe Alzheimer's disease. Memantine, an NMDA receptor agonist, is shown to slow the progression of manifestations and to improve cognitive function.
A nurse is assessing a client who has panic disorder and has been taking paroxetine. Which of the following assessments should the nurse identify as an adverse effect of the medication? a. peripheral edema b. chest congestion c. shuffling gait d. weight gain
Answer: d. weight gain Rationale: Paroxetine is an SSRI- expected adverse effects are weight gain, nausea, headaches, insomnia, and sexual dysfunction
A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply) A. has experienced symptoms of the disorder for less than 2 weeks. B. fears a physical integrity threat to self. C. feels detached and estranged from others. D. experiences fear and helplessness. E. is lethargic and somnolent. F. is happy to be home.
Answers B, C, D Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment, and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.
