Practice A

Question 1

The client is at risk of developing _____________________ due to ________________________________________________

A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a selegiline 12 mg transdermal patch once daily.

Answer 1

hypertensive crisis; consuming foods high in tyramine

Question 2

A nurse on a mental health unit is caring for a client w/ schizophrenia.

After reviewing the client’s medical record, the nurse should notify the provider of which of the following findings?

Select the 5 unexpected findings that require notification of the provider.

Answer 2

temperature, bowel sounds, ANC level, myalgia, and heart rate

Question 3

A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication?

A nurse is caring for a client who has posttraumatic stress disorder and a new prescription for sertraline.

Answer 3

temperature, sodium level, diaphoresis, insomnia, headache, and blood pressure.

Question 4

A nurse is caring for a client who has impaired cognition.

A nurse is updating the client’s plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated or contraindicated for the client.

Answer 4

when addressing the client, approach them from the front when possible. -ANTICIPATED
Use a vest restraint to keep the client in a medical recliner- CONTRAINDICATED
Ensure the bed is kept at a working height for the nurse- CONTRAINDICATED
Give directions to the client slowly and in a moderate tone of voice- ANTICIPATED
Decrease sensory stimulation- ANTICIPATED
Keep the lights off in the client’s bedroom and bathroom at night- CONTRAINDICATED
Assign the client to a room near the nurses’ station.- ANTICIPATED

Question 5

A nurse is caring for a newly admitted client.

For each potential assessment finding, click to specify if the finding is consistent with positive or negative symptoms of schizophrenia.

Answer 5

delusions of grandeur, clang associations, catatonia - positive
alogia and withdrawal from social activities- negative

Question 6

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

Answer 6

a client who is taking lamotrigine and has developed a rash

Question 7

a nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Answer 7

gather supplies for endotracheal intubation

Question 8

a nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Answer 8

mild

Question 9

a nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk of suicide?

Answer 9

“its easier to talk about my feelings now”

Question 10

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect for methylphenidate?

Answer 10

tachycardia

Question 11

a nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client’s plan of care?

Answer 11

permit the client to perform daily rituals to decrease anxiety

Question 12

a nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

Answer 12

the client has COPD

Question 13

a nurse is caring for a child who has conduct disorder and is hebaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Answer 13

reduce environmental stimuli

Question 14

a nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Answer 14

spending adequate time with a client who is verbally abusive

Question 15

a nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Answer 15

“i will update the plan of care as a client’s manifestations of depression change.”

Question 16

a nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

Answer 16

inform the client that this admission is confidential

Question 17

a nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?

Answer 17

guided imagery

Question 18

a nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5mg/mL. How many mL should the nurse administer?

Answer 18

1.5mL

Question 19

a nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hour ago following a motor-vehicle crash. The client’s admission blood alcohol level was 325 mg/dL (0 to 50 mg/dL). Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Answer 19

blood pressure 154/96 mm Hg

Question 20

a nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Answer 20

set realistic limits on the clients behavior

Question 21

Select the 6 findings in the client’s medical record that are manifestations of the client’s diagnosed personality disorder.

A nurse is caring for a client who has a personality disorder.

Answer 21

stealing money from family to cover credit card charges, anxious if left alone, hypersexualization, married multiple times, incidences of self-injury, and physical altercations

Question 22

For each potential provider’s prescription, click to specify if the prescribed therapy is expected with obsessive compulsive disorder, dementia, or borderline personality disorder. Each therapy can support more than one disease process.

A nurse is caring for a client who has a personality disorder.

Answer 22

ocd- systemic desensitization, fluoxetine 20mg PO daily
dementia- validation therapy, donepezil 5mg PO daily
bpd- dialectical behavior therapy, fluoxetine 20 mg PO daily

Question 23

Complete the following sentence by using the lists of options.

A nurse is caring for a client who has a personality disorder.

Answer 23

violent behavior; increased agitation

Question 24

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

A nurse is caring for a client who has a personality disorder.

Answer 24

haloperidol- ANTICIPATED
hold next dose of buspirone- CONTRAINDICATED
request change of diet- NONESSENTIAL
request prescription- CONTRAINDICATED
calmly approach client and state “ you seem agitated…”- ANTICIPATED

Question 25

The nurse is caring for the client. Which of the following actions should the nurse take? ## Footnote A nurse is caring for a client who has a personality disorder.

Answer 25

maintain continuous observation of the client while in restraints, conduct debriefing with the client and other staff

Question 26

The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined. ## Footnote A nurse is caring for a client who has a personality disorder.

Answer 26

client attempts to bite staff- DECLINED client follows instructions- IMPROVED client is silent and glares- NO CHANGE client verbalizes precipitating factors to violent outburst- IMPROVED

Question 27

a nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Answer 27

suggest forming a weekly support group for parents who have experienced the death of a child

Question 28

a nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Answer 28

assertive community treatment

Question 29

a nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

Answer 29

the client should obtain a sponsor before discharge for an increased chance of recovery

Question 30

a nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse incluse as a method of secondary prevention?

Answer 30

Establish screening programs to identify at-risk clients

Question 31

a nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

Answer 31

a client who has borderline personality disorder threatened to harm their roomate.

Question 32

a nurse is in a clinic assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

Answer 32

"I feel so empty without my wife that it's hard to get up every morning."

Question 33

a nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?

Answer 33

call for a team of staff members to help with the situation.

Question 34

a nurse is preparing to administer prescribed clozapine to a client. Which of the following client laboratory results should the nurse review prior to adminsitering the clozapine.

Answer 34

absolute neutrophil count

Question 35

a nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the following client findings should the nurse identify as a contraindication for receiving clozapine?

Answer 35

WBC count 2,500/mm^3 (5,000 to 10,000/mm^3)

Question 36

a nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?

Answer 36

offer the client high-calorie finger foods frequently

Question 37

a nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

Answer 37

easily distracted

Question 38

a nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?

Answer 38

experiences feelings of isolation

Question 39

a nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Answer 39

encourage the client to drink 125mL of fluid each hour while awake

Question 40

during a client's initial interview in a mental health inpatietn setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

Answer 40

the client is interested in what the nurse is saying

Question 41

a nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

Answer 41

"if you do my homework for me, i won't bother you for the rest of the day."

Question 42

a nurse is planning for a client who is to undergo ECT. Which of the following actions should the nurse include in the plan?

Answer 42

monitor the clients cardiac rhythm during the procedure

Question 43

a nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Answer 43

language delay

Question 44

a nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Answer 44

hypertension

Question 45

a nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

Answer 45

promote the use of music to compete with the client's auditory hallucinations

Question 46

a school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder?

Answer 46

lack of interest in an upcoming holiday

Question 47

a nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take?

Answer 47

ensure security personnel are available in the background to assist if the client's behavior escalates

Question 48

while observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

Answer 48

the client needs excessive external input to make everday decisions

Question 49

a nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the followings findings should the client's partner report to the provider

Answer 49

inability to sleep

Question 50

a nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?

Answer 50

nonmaleficence

Question 51

a nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

Answer 51

dark urine

Question 52

a nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

Answer 52

early identification of changes, such as decreased social involvement, it is important

Question 53

a nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Answer 53

emotional lability

Question 54

a nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Answer 54

anhedonia

Question 55

a nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

Answer 55

"lets talk about what is upsetting you."

Question 56

a nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

Answer 56

a client was administered one-half of the prescribed dose of medication

Question 57

a nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client?

Answer 57

assess the client every 15 minutes

Question 58

a client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too" Which of the following actions should the nurse take?

Answer 58

move the client who has bipolar disorder to a private room

Question 59

a nurse on an acute mental health facility is receiving a change-of-shift report for our clients. Which of the following clients should the nurse assess first?

Answer 59

a client who is expressing delusions of persecution

Question 60

Click to highlight the findings in the medical record that indicate maladaptive uses of defense mechanisms. ## Footnote A nurse is caring for a client who has panic disorder.

Answer 60

returned from exercis class in agitated state, and Client tells the nurse, "That exercise instructor was one of my favorite people here. we had so much in common. But now I know their true nature. She's evil!"