exam 2

Question 1

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions
should the nurse identify as the priority?

Advise the client to take frequent sips of water.

Recommend that the client exercise regularly.

Consult a dietitian for a calorie-controlled diet plan.

Instruct the client to avoid driving during initial therapy.

Answer 1

Instruct the client to avoid driving during initial therapy.

Question 2

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will take prescribed medications as scheduled.

The client will express feelings of frustration.

The client will refrain from self-mutilation.

The client will participate in group therapy.

Answer 2

The client will refrain from self-mutilation.

Question 3

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which
of the following statements should the nurse make?

“It will be better for you to keep busy to avoid thinking about your child’s death.”

“You will complete the grieving process about a year after your child’s death.”

“The grief process will start once your child actually dies.”

“It is not uncommon to feel angry toward yourself or others.”

Answer 3

“It is not uncommon to feel angry toward yourself or others.”

Question 4

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5
mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a
trailing zero.)

Answer 4

13.75 = 14 mL

Question 5

what is expected of a client with bulimia nervosa?

Answer 5

TOOTH EROSION.

A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.

Question 6

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the
priority for the nurse to notify the provider?

The client’s chart indicates a 1.36-kg (3-lb) weight gain in 1 month.

The client reports an inability to breathe easily.

The client’s laboratory results indicate a fasting blood glucose level of 130 mg/dL (74 to 106 mg/dL)

The client reports having recently started smoking cigarettes.

Answer 6

The client reports an inability to breathe easily.

Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations and should be reported to the provider.

Question 7

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include
as increasing the risk for depression?

Male gender

Hyperthyroidism

Substance use disorder

Being married

Answer 7

Substance use disorder

Question 8

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group’s time. Which of the following interventions should the nurse implement?

Tell the client to talk less or risk being removed from the meeting.

Ask group members to discuss their feelings about this client’s monopolizing behavior.

End the group meeting and take the client aside to discuss the disruptive behavior.

Focus on other group members and ignore the client who is doing all the talking.

Answer 8

Ask group members to discuss their feelings about this client’s monopolizing behavior.

Question 9

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by
the client indicates an understanding of the teaching?

“I will spend extra time at work to keep from feeling depressed.”

“I will talk about my feelings with a close friend.”

“I will be able to learn how to prevent my partner’s attacks.”

“I will use meditation instead of taking my antidepressant.”

Answer 9

“I will talk about my feelings with a close friend.”

Question 10

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following
interventions should the nurse include in the plan?

Document the client’s behavior every 8 hr.

Limit the client’s fluid intake to 50 mL/hr.

Renew the prescription for the client every 4 hr.

Toilet the client every 4 hr.

Answer 10

Renew the prescription for the client every 4 hr.

Question 11

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-
counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Lansoprazole

Naproxen

Magnesium hydroxide

Phenylephrine

Answer 11

Phenylephrine.

Because tranylcypromine, is an MAOI antidepressant .

Combining monoamine oxidase inhibitors (MAOIs) with phenylephrine is dangerous because MAOIs inhibit the breakdown of phenylephrine, significantly increasing its effects on blood pressure. This can lead to a severe hypertensive crisis, which is a sudden and dangerous spike in blood pressure

Question 12

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following
findings indicates the nurse should administer benztropine 2 mg IM?

Shuffling gait

Hypotension

Decreased WBC count

Blurred vision

Answer 12

Shuffling gait.

Benztropine is used to treat parkinsonism manifestations, such as shuffling gait due to extrapyramidal symptom.

Question 13

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client’s turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer.

Prompt the client to give a response.

Move on to the next client.

Offer the client a suggestion for a goal.

Answer 13

Allow the client time to formulate an answer.

Question 14

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Answer 14

encourage frequent rest periods throughout the day.

Question 15

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK)

Increased low-density lipoproteins (LDL)

Decreased fasting blood glucose

Decreased aspartate aminotransferase (AST)

Answer 15

Increased creatine phosphokinase (CPK).

An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

Question 16

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?

Blurred vision

Orthostatic hypotension

Dry mouth

Acute dystonia

Answer 16

Acute dystonia

Question 17

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations.

The client is exhibiting echolalia.

The client reports loss of motivation.

The client is exhibiting blunted affect.

Answer 17

The client reports command hallucinations.

Question 18

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

“You might notice an increase in saliva while taking this medication.”

“You might experience difficulties with sexual functioning while taking this medication.”

“You should expect an improvement in symptoms of depression in 3 to 4 days.”

“You may notice a temporary ringing in the ears when starting this medication.”

Answer 18

“You might experience difficulties with sexual functioning while taking this medication.”

Question 19

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?

“I put in extra hours at work so I won’t think about drinking.”

“I know that wine is good for my heart, so that’s why I drink some each evening.”

“I make up for my drinking by taking my partner on nice vacations.”

“I am able to go to work every day, so I don’t have a problem.”

Answer 19

“I am able to go to work every day, so I don’t have a problem.”

Question 20

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client’s partner indicates an understanding of the teaching?

“I will avoid social events until my partner has completed treatment.”

“It is important for me to focus my attention on my partner’s addiction.”

“I will not take charge of my partner’s work responsibilities.”

“I want my partner to promise to change addictive behaviors.”

Answer 20

“I will not take charge of my partner’s work responsibilities.”

Question 21

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed
consent?

A 35-year-old client who has major depressive disorder

A 50-year-old client who has a blood alcohol level of 80 mg/dL

A 17-year-old client who lives with friends

A 65-year-old client who just received a dose of morphine

Answer 21

A 35-year-old client who has major depressive disorder

Question 22

A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

“I am going to order a wheelchair for when I’m unable to walk.”

“I am going to stop paying my bills since I won’t be around much longer.”

“I wish you would go take care of somebody who actually needs you.”

“I am sure I’ll be able to continue to care for myself without help.”

Answer 22

“I am going to order a wheelchair for when I’m unable to walk.”

Question 23

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

Potassium 3.6 mEq/L (3.5 to 5 mEq/L)

Temperature 36.1° C (96.9° F)

Heart rate 54/min

Answer 23

Total body fat 8.7% (this is critically low).

Question 24

A nurse in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet
performance. Which of the following statements by the parent acknowledges the client’s diagnosis?

“They work so hard at ballet. Will they still be able to perform?”

“They’re happier with their appearance now that they’ve lost some weight.”

“They told me they were tired, so I did their chores for them today.”

“They won’t let me take the trash from their room. I’m concerned about what they have in there.”

Answer 24

“They won’t let me take the trash from their room. I’m concerned about what they have in there.”

Question 25

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? Include a liquid supplement with meals. Identify the client's trigger foods. Allow the client at least 1 hr for each meal. Weigh the client at bedtime each day.

Answer 25

Identify the client's trigger foods.

Question 26

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? "It appears as though you would like to open the door." "You will feel more comfortable after you've been here for a while." "It is okay to not want to be here." "You really shouldn't be pushing on the door."

Answer 26

"It appears as though you would like to open the door."

Question 27

positive and negative findings

Answer 27

Question 28

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? "Information regarding clients should remain confidential until after their death." "Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states." "As long as client identity is disguised, their health information can be shared between professionals on the internet." "In the event a client threatens harm to others, medications can be administered without consent."

Answer 28

"In the event a client threatens harm to others, medications can be administered without consent."

Question 29

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? Clang association Word salad Neologism Echolalia

Answer 29

Clang association

Question 30

A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? Obtain the weight of a client who has bipolar disorder and is experiencing mania. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome. Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

Answer 30

Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds.

Question 31

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? Increased confusion Sleep disturbances Cluttered environment Inappropriate dress

Answer 31

Inappropriate dress

Question 32

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Sedation Rhinorrhea Bradycardia Hypothermia

Answer 32

Rhinorrhea. The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

Question 33

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? The client recently lost a grandparent in a motor vehicle crash. The client's town was hit by a tornado. The client's youngest child is leaving for college. The client is ambivalent about their upcoming retirement.

Answer 33

The client recently lost a grandparent in a motor vehicle crash.

Question 34

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? Raise the pitch of the voice when speaking to the client. Begin the interview by explaining the plan of care. Interview the client in a private setting. Ask the client to complete a detailed questionnaire.

Answer 34

Interview the client in a private setting.

Question 35

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? Orient the client to person, place, and time. Assist the client with deep-breathing exercises. Calm the client by using therapeutic touch. Have the client sit alone in a quiet room.

Answer 35

Assist the client with deep-breathing exercises.

Question 36

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? Complete documentation about the client's status every hour while they are in restraints. Maintain the client in restraints for a minimum of 4 hr. Apply restraints when other means of managing the client's behavior have failed. Request that the provider assess the client within 8 hr of the application of restraints.

Answer 36

Apply restraints when other means of managing the client's behavior have failed.

Question 37

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? Offering self Use of silence Attention to body language Reflection of feelings

Answer 37

Attention to body language

Question 38

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A school-age child who has bruises on the knees An older adult client who is bedbound and has a stage IV pressure ulcer An adolescent who has a vaginal candida infection A young adult who is pregnant and has a sprained ankle

Answer 38

An older adult client who is bedbound and has a stage IV pressure ulcer

Question 39

The nurse is assessing the client. Select the 5 findings that require follow-up.

Answer 39

Blood alcohol concentration (BAC). temperature Respiration rate LOC N/V

Question 40

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take? Ask the client to identify the bomb in the room. Initiate disaster protocols per facility policies and procedures. Assess the client for evidence of a perceptual disturbance. Convince the client that there is no bomb in their room.

Answer 40

Assess the client for evidence of a perceptual disturbance.

Question 41

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? Sore throat Photophobia Hand tremors Constipation

Answer 41

Hand tremors

Question 42

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? Confront the staff member. Encourage the client to report the incident. Document the incident in the client's health record. Report the occurrence to the charge nurse.

Answer 42

Report the occurrence to the charge nurse.

Question 43

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? An adolescent family member who questions parental authority A family with three generations in the same household Older children who are responsible for their younger siblings Two adults and their children from prior relationships in the same household

Answer 43

Older children who are responsible for their younger siblings

Question 44

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? Move the client to a room near the nurses' station. Limit visitors until the client is oriented to the environment. Tell the client that their partner is deceased. Talk with the client about activities they enjoyed with their partner.

Answer 44

Talk with the client about activities they enjoyed with their partner.

Question 45

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? Decrease distractions during meal times. Provide positive feedback when the child completes a task. Clearly identify consequences for unacceptable behavior. Remove unnecessary equipment from the child's surroundings.

Answer 45

Remove unnecessary equipment from the child's surroundings. The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.

Question 46

A charge nurse is providing an in-service about manifestations that can precede violent behavior in clients. Which of the following should the nurse include in the teaching as a predictor for violence? Decreased energy Dull affect Poor hygiene Quiet voice

Answer 46

Quiet voice.

Question 47

O .. A nurse is evaluating the lethality of a client's suicide plan. Which of the following methods should the nurse identify is a higher-risk? Cutting wrists Ingesting pills Hanging oneself Inhaling natural gas

Answer 47

Hanging oneself

Question 48

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? Select all that apply. Somnolence Increased appetite Malaise Yellowing skin Fever

Answer 48

Malaise. Yellowing skin. Fever.

Question 49

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding?

Answer 49

“I may experience feelings of resentment.” “I will probably withdraw from others.” “I can expect to experience changes in sleep.”

Question 50

when should donepezil be taken?

Answer 50

this is alzheimer's medication. Taken right before bed, with or without food

Question 51

A home health nurse is making a visit to a client who has Alzheimer’s Disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury?

Answer 51

Install extra locks at the top of exit doors.. Place the client’s mattress on the floor. Install light fixtures above stairs.

Question 52

positive symptoms of schizophrenia that are effectively treated by first-generation antipsychotics.

Answer 52

Auditory hallucinations. Delusions of grandeur. Severe agitation.

Question 53

Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)?

Answer 53

Drooling. Involuntary movements. Pacing.

Question 55

Contraindications of Bupropion

Answer 55

History of seizure. Recent head injury. Stroke. Use of MAOI’s.

Question 56

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following findings are expected for this disorder?

Answer 56

Substance use. Irritability. Aggressiveness.

Question 57

A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include?

Answer 57

Bullying of others. Law-breaking activities. Threats of suicide.

Question 58

A nurse is assisting the guardians of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend?

Answer 58

Develop a reward system for acceptable behavior.. Encourage the child to participate in school sports.. Be consistent when addressing unacceptable behavior..

Question 59

Confabulation

Answer 59

The client can make up stories when questioned about events or activities that they do not remember

Question 60

Perseveration

Answer 60

The client avoids answering questions by repeating phrases or behavior.

Question 61

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect?

Answer 61

Family report of personality changes. Hallucinations. Restlessness.

Question 62

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

Answer 62

Excessive worry for 6 months. Restlessness. Sleep disturbance

Question 63

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Answer 63

Stay with the client and remain quiet.