A nurse has placed a client who has become physically aggressive into seclusion. which of the following
a. Document the client behavior 15 min.
b. Obtain the provider prescription within 06min
c. Monitor the client vital every4 hr.
d. Offer client food and fluids every 2hr.
2. A nurse is assessing a client restless and constantly mutters to himself. which of the following finding should lead the nurse to suspect delirium?
a. the client speech is slow and repetitious.
b. the client manifestation developed suddenly
c. The client has a flat affect
d. the client is unable to recognize objects
3. The nurse on a mental health unit placed a client in mechanical restraint after the client assaulted another client. Which of the following action should the nurse take?
a. Have the provider assess the client within 1hr after applying the restraints
b. obtains a prescription for restraints on an as- needed basis.
c. Request that the provider renew the prescription for restraints every 8 hr.
d. Evaluate the client hourly while the restraints are applied
4. A nurse is planning care for a newly admitted client who has anorexia nervosa. Which following intervention should the nurse include in the plan?
a. Negotiate with the how much weight she should gain each week
b. Weigh the client weekly for first month.
c. Notify the client about designated time for meals.
d. Decrease the client daily intake of fiber.
5. An older adult client brought to the mental health clinic by her daughter. the daughter reports that her mother is not eating and seems uninterested in routine activities. the daughter states, I’m so worried that my mother is depressed. which of following responses should the nurse make?
a. older adults are usually diagnosed with depressive disorder as they age.
b. Everyone gets depressed from time to time
c. Tell me the reasons you think your mother is depressed
d. you should not worry about this, because depressive disorder is easily treated
6. A charge nurse is discussing the care of the client who has a substance use disorder with a staff nurse. which of the following statements by the staff nurse should the charge nurse identify as countertransference?
a. The client asked me to go no a date with him but refused.
b. The client generally shares his feeling during group therapy sessions
c. The client is just like my brother who finally overcame his habit
d. The client needs to accept responsibility for his substance use.
7. A nurse is teaching about deep-breathing exercise with a client who reports experiencing intense stress at work. Which of the following statements by the client indicated an understanding of the teaching?
a. I will focus on how the muscles in my stomach feel with each breath.
b. I will inhale through my mouth and exhale through my nose
c. I will hold my breath for 5 or 6 second each time
d. I will focus on the cause of my stress during the exercise
8 A nurse is caring for a client who has schizophrenia and is taking clozapine. which of the following finding is the priority for the nurse to report to the provider?
Sore throat
Heart rate104/min
Random blood glucose 130 mg /dl
Nausea
9 . A nurse is caring for a client who has been taking valproic acid. which of the following is an expected outcome of the medications?
The client has decreased anxiety
The client report absence of auditory hallucinations
The client has decrease euphoric mood.
The client reports improved short-time memory
10A nurse caring for client who states am too embarrassed to tell anyone what I did last night of the following responses should the nurse make?
lots of people feel ashamed to tell their secrets
you will feel better if you tell me what did last night.
Let’s discuss what you feel embarrassed about.
You should not feel embarrassed to talk to me
11 A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply
Bradycardia
Hypotension
Lanugo
Russell sign
Diarrhea
12 A nurse is conducting an admission with new client who tell the nurse , my life is so stressful can’t take it anymore. Which of the following responses should the nurse make first?
Tell me what makes you feel stressed
Let’s talk more about what you are experiencing
How have you dealt with stress in the past?
Are you thinking of harming yourself?
13 A nurse is assessing a client who has a history of substance use disorder and states, people are out to get me. the client has tachycardia and hypertension. the nurse should suspect acute toxicity of which the following substances.
Heroin
Cocaine
Opium
Alcohol
14 A nurse is caring for a client who report that he is angry with his partner because she think he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. which of the following of the defense mechanism is the client demonstrating?
Denial
Compensation
Displacement
Rationalization
15 A nurse is caring client whose partner died 6 ago . which of the following findings is the nurses priority?
The client relates that he is angry that provider did not save his partner life.
The client frequently recalls negative experiences that occurred during his marriage
The client states that he is unable to eat more than once a day
The client says he feels guilty about not spending more time with his partner.
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD which of the following statement by the client indicates an accurate understanding of this medications effect?
This medicine will help me relax and feel less anxious.
I need to tell my doctors if I start gaining weight
I will take my medicine at bedtime because it will make me drowsy.
I know that I will be able to think more clearly now.
A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegilline?
Fluoxetine
Acetaminophen
Warfarin
Calcium carbonate
A nurse in an inpatient facility is caring for a client who is has anxiety disorder. which of the following actions should the nurse take while the client is experiencing an acute panic attack?
Encourage the client to describe their feelings in a journal.
Administer a dose of alprazolam to the client
Encourage the client to watch television as a distraction
Administer a dose of atomoxetine to the client.
A nurse in a mental health facility is reviewing the laboratory result of a client who is taking lithium carbonate. which of following findings places the at risk for lithium toxicity?
Aspartate aminotransferase 40 units/l
Calcium10.0mg/dl
Sodium 132mEq/l
WBC 6,000/mm
A nurse is caring for a client has an anxiety disorder and scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. which of the following actions should the nurse take?
Request another nurse to review the procedure with the client.
Inform the client that they have legal right to refuse treatment at any time
Obtain consent from the client’s family member.
Encourage the client to have the procedure
A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. which of the following findings indicates the client’s adherence to the treatment plan?
The clients current BMI is 14.
The client report following various cooking blogs.
The client potassium level is 3.2 mEq/l
The client states that she knows she can’t bd perfect
A nurse is receiving change of shift report for four clients. which of the following clients should the nurse see first?
A client who is taking lithium report weight gain
A client who has schizophrenia and is experiencing olfactory hallucination
A client who is talking clozapine and report sore throat
A client who has bipolar disorder and is speaking loudly
A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by the partner. after a rapid assessment. which of the following actions should the nurse plan to take next?
Request a mental health consultation for the client.
Off prophylactic medication to prevent STLS.
Conduct a pregnancy test.
Provide a trained advocate to stay with the client.
A nurse is caring for client who is has schizophrenia. the client’s employer calls to discuss the client’s condition. Which of the following is the appropriate nursing action?
Contact the provider.
Contact the facility legal department
Consult the client’s family.
Consult the client.
A nurse in a mental health facility is making plans for a client’s discharge. which of the following interdisciplinary team members should the nurse contact to assists the client with housing placement ?
Clinical nurse specialist
Occupational therapist
Social worker
Recreational therapist
A nurse in a long- term care facility is caring for a client. the nurse should Identify that which of the following conditions places the client at an increased risk for developing delirium?
WBC count 13,000/mm
Hypertension
Neuropathy
Bun 16 mg/dl
A home health nurse visits a client who lost their partner 2 years ago. which of the following behaviors by the client indicates a maladaptive grief response?
The client relocated from a house to an apartment
The client gives ways some of the partner belongings
The client expresses feeling of guilt.
The client is unable to perform perform basic hygiene tasks.
A nurse is reviewing the laboratory report of a client who has a panic disorder and is talking clonazepam. which of the following lab results should the nurse report to the provider?
Platelets 100,000mm
WBC count 8,000/mm
RBC count 4.9 million/mm
Hemoglobin 16g/dl
A nurse is assessing a client who is has depression and take phenelzine. the client reports eating pepperoni pizza while out on a pass during lunchtime. which assessing should the nurse perform
Bowel sound
Pupil response
Oxygen saturation
Blood pressure
A nurse a mental health facility is caring for a client who is being aggressive toward other clients. which of the following actions is the priority for he nurse to take?
Assist the client to explore techniques to reduce stress.
Suggest the client make a list of the things that make him angry
Ask the client if he intends to harm others.
Role model health ways to express anger
A nurse is developing a behavioral contract with a client who has antisocial personality disorder . which of the following client goals should the urse include in the contract?
Decrease the number of verbal outbursts.
Use bargaining skills for behavioral consequences.
Increase self-esteem
Use projection during groups therapy.
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to reports to other disciplines?
Poor problem solving skills
Psychomotor retardation
Markedly neglected hygiene
Significant weight loss
A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation .which of the following assessment findings in the client history should the nurse reports to the provider ?
Hypothyroidism
Knee arthroplasty 1 month ago
Recent head injury
Hepatitis B infection
A nurse is assessing a client who who has schizophrenia. Which of the following findings should the document as positive symptoms of schizophrenia? select all that apply
Impaired memory
Auditory hallucination
Flight of ideas
Decreased motivation
Delusion of grandeur
A nurse is caring for a school – age child who has conduct disorder and requires wrist restraints. which of the following action should the nurse take?
Obtain a prescription for the restraints within 2hr of initiating them
Have the child perform range of motion exercises every3hr
Ensure three fingers will fit between the child’s wrist and the restrain.
Monitor the child vital signs every15 min
A nurse is caring for client who has borderline personality disorders. which of the following actions should the nurse take?
Demonstrate a sympathetic attitude toward the client when providing care
Encourage the use of countertransference for the client.
Maintain consistency is assigning health care staff for the client
Provide consistent boundaries for the client
A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?
“Are you having thoughts about harming yourself?”
Who do you talk to when you need help?
What do you usually do to cope with problems in your life?
How do you think this event is affecting your life right now?
13: A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why the health care team. Which of the following actions should the nurse take?
Inform the client that ECT does not require client consent.
Tell the client he cannot refuse the treatment because he was involuntarily committed.
Ask the client’s family to encourage the client to receive ECT.
Document the client’s refusal of the treatment in the medical record.
14: A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
+2 edema of the lower extremities
Bun 21 mg/dL
Blood pH 7.60
Lanugo covering the body
15: A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse’s station?
A client who has moderate-stage Alzheimer’s disease
A client who has a history of dependent personally disorder
A client who has schizotypal personality disorder
A client who has a history of alcohol use disorder
16: A nurse in a provider’s office is assessing a school- age child who was a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?
Report suspected abuse to child Protective Services
Ask the child how the injury occurred.
Determine the immediate safety needs of the child.
Request that the parent leave the room while interviewing the child.
17: A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Request a prescription for varenicline from the client’s provider.
Initiate facility procedures for emergency commitment
Assess the client using the CAGE questionnaire.
Inform the client about policies for dispensing methadone.
18: A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
A client who states she did not get a promotion because her boss dislikes her.
A client who has stomach pain before presenting a project to his coworkers.
A client states she will worry about her grades after she finishes planning a party.
A client whose partner died 5 years ago still talks about him in the present tense.
19: A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
Assess the need for physical restraints.
Discuss the purpose of the medication with the client.
Demonstrate how to verbally de-escalate the situation.
Stop the newly licensed nurse from administering the medication.
20: A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
Remain with the client for 1 hr. after meals.
Weigh the client every other day.
Plan menu with the client.
Offer snacks when the client is hungry.
21: A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?
The client is the oldest of their siblings.
The client has several siblings.
The client’s mother has asthma.
The client’s father lives in the client’s home.
22: A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestation?
Decreased heart rate
Hyperglycemia
Decreased blood pressure
Hyperthermia
23: A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan?
Refer the client to a self-help group.
Contact a close relative of the client to discuss the discharge plan.
Teach the client to practice systematic desensitization.
Request a discharge prescription for buprenorphine for the client.
24: A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which is the following actions should the nurse take?
Inform the client that he does not have the right to refuse the medication.
Implement consequences until the client takes the medication.
Offer the client the medication at the next scheduled does time.
Administer the medication to the client via IM injection.
25: A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?
Encourage the use of problems-solving skills.
Manage conflict within the group.
Establish a rapport with group members
Maintain the group’s focus on identified issues
26: A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
Refusing to participate in group activities
Expressing frustration regarding unit rules
Reacting to the nurse as though she were his mother
Talking negatively about other staff members
27: A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?
The client’s speech is slow and repetitious.
The client’s manifestation developed suddenly
The client has a flat affect.
The client is unable to recognize objects.
28: A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Document the client’s behavior every 15 min.
Obtain the provider’s prescription within 60 min.
Monitor the client’s vital sign every 4hr.
Offer the client food and fluids every 2hr.
29: A nurse on a mental health unit placed a client in mechanical restraint after the client assaulted another client. Which of the following actions should the nurse take?
Have the provider assess the client within 1hr after applying the restraints.
Obtain a prescription for restraints on an as-needed basis.
Request that the provider renew the prescription for restraints every 8 hr.
Evaluate the client hourly while the restraints are applied.
30: An older client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating seems uninterested in routine activities. The daughter of states, “I’m so worried that my mother is depressed.” Which of the following responses should the nurse make?
Older adults are usually diagnosed with depressive disorder as the age.
Everyone gets depressed from time to time
Tell me the reasons you think your mother is depressed.
You shouldn’t worry about this, because depressive disorder is easily treated.
40 A nurse is assessing client who has derlium . which of the following findings requires immediate intervention by the nurse ?
Inappropriate mood swings
Rapid mood swings
Command hallucination
Impaired memory
A nurse is caring for a client has bipolar disorder and is refusing to take prescribed medication which of the following ethical principles is the nurse displaying when he supports the clients refusal of medication ?
Veracity
Justice
Autonomy
Beneficence
A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. which of the following actions should the nurse take?
Change the subject when the client becomes upset
Discourage the client from forming new relationships.
Allow the unlimited time for the grieving process .
Offer the advice about various treatment choices
A nurse is caring for a client who has Alzheimers disease .which of the following findings should the nurse expect?
Rapid mood swings
Altered level of consciousness
Excessive motor activity
Failure to recognizer familiar objects
A nurse is leading a grief support group for beraved clients. Which of the following statements should the nurse report to the provider as an indication of clinical of depression?
I feel like I’m angry at the whole world right now.
I done know how I could cope if I did not have my family support.
I done feel anything but numbness anymore.
It be a long time before I’m happy again
A nurse is caring for client who has borderline personality disorder and has been engaging in self – mutilation .the nurse should encourage the client to participate in which of the following groups ?
Dialectical behavior treatment group
Dual diagnosis treatments group
Co-dependents support group
Desensitization therapy
A nurse caring for a school -age child who has a new diagnosis of attention – deficit hyperactivity disorder . the nurse should anticipate a prescription for which of the following medication
Rispenidone
Valproate
Lithium
Methlpenidate
The I nurse assisting with obtaining informed consent for a client who has been declared legally incompetent .which of the following actions should the nurse take?
Ask the charge to obtain informed consent .
Explain implied consent to the clients family.
Request that the clients guardian sign the consent.
Contact the facility social work to obtain the consent
A nurse caring for a client who has depression following a recent job loss .which of the following questions should the nurse ask to asses the client personal coping skills
Can you describe how currently feelings
How have you dealt with similar situation in the past
Do you see your current situation affecting your future
How does this situation affect the your life nurse
A nurse caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm . which of the following action should the nurse take?
Explain the medication cause a temporary rash
Apply hydrocortisone cream on the client rash
Withhold the next dose of the medication
Ask the about a recent change in laundry detergent
A home health nurse is caring a client who is in the continuation phase of major depressive disorder .the client states , I feel unmotivated and done feel leaving my home . which of the following recommendations should the nurse make to addresses the client social isolation?
Practice guided imagery each morning
Join a loving impact exercise class
Write in a journal daily
Enroll in an online self- help course
A nurse is providing counseling for the a family that consists of two parents and their two adolescent children . which of the follssion owing members should the nurse identify as acting in the role of monopolize?
The adolescent son who refused to share personal feelings
The adolescent daughter who attempts to dominate the discussion
The mother who expresses hostility toward her spouse
The father who intervenes whenever the siblings argue
A nurse is reviewing the medical record of a client who is to begin ariprazole .the nurse should identify that which of the following findings is a contraindication
Asthma
Seizure disorder
Crohn’s disease
Hypothyroidism