question

interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. The nurse should ask which of the following questions to determine the pt's ability to cope with this situation?

answer

"To whom do you talk when when you feel overwhelmed?"

question

Caring for a pt who gave birth to a stillborn baby. Appropriate statement?

answer

"I'll stay with you just in case you want to talk."

question

Assessing a pt who sustained injuries 12 hrs ago following a MVC. The blood alcohol lvl was 325 mg/dL. Findings that indicate alcohol withdrawal?

answer

BP 154/96 mm Hg

question

New diagnosis of Azheimer's disease and is to start taking donepezil. Statement to be included in the teaching?

answer

"Take this medication in the evening at bedtime."

question

Discussing a 12-step program with a pt who has alcohol use disorder and is in a n acute care facility undergoing detoxification. Information to be included in the teaching?

answer

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

question

Schizophrenic pt. is trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Appropriate action?

answer

Assess the client for evidence of a perceptual disturbance.

question

Pt with major depression disorder and a NEW prescription for tranylcypromine. Which OTC med that the pt reports taking should alert the nurse to a potential adverse rxn?

answer

Phenylephrine

question

Assessing a pt. with schizophrenia. Findings that are negative symptoms?

answer

Anhedonia

question

ED nurse caring for a female adolescent who has a dx of bulimia nervosa and had a fainting episode. Statements by mother that acknowledges the daughter's dx?

answer

"She won't let me take the trash from her room. I'm concerned about what she has in there."

question

Assessing a pt. who has major depressive disorder and has been receiving amitriptyline for 1 wk. Following expected outcome?

answer

Greater risk of attempting suicide as affect and energy improve.

question

expected clinical manifestations of PTSD?

answer

Experiences feelings of isolation

question

Criteria required for hospitalization of anorexia nervosa?

answer

Temperature 35.6*C (96.1*F)

question

Pt is experiencing alcohol withdrawals. Which medication should be administered first?

answer

Diazepam 5 mg IV bolus

question

Pt. with dx of depression and attending a group therapy. Nurse asks each member to identify 1 goal for the day. The pt. does not respond when it is her turn. Appropriate action before repeating the request to the pt.?

answer

Allow the client time to collect her thoughts.

question

Nurse observes a pt who has acute mania hit another pt. First action to take?

answer

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

question

Teaching to a pt. who is to begin undergoing light therapy at home to treat seasonal affective disorder. Teaching to include?

answer

Wear sunglasses when outdoors.

question

Pt. with bipolar disorder is to be discharged home with a prescription for lithium. Which statement indicates effective teaching?

answer

"I should eat a regular diet with normal amounts of salt and fluids."

question

Action that is an example of the ethical principle of justice?

answer

Spending adequate time with a client who is verbally abusive.

question

Nurse is working with a group of parents who recently lost a child. Appropriate action to take?

answer

Suggest forming a weekly support group for parents who have experienced the loss of a child.

question

Planning care for a pt who has a new prescription for olanzapine. Priority intervention?

answer

Instruct the client to avoid driving during initial therapy.

question

Preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Referrals to initiate? (select all)

answer

Occupational therapy Meal delivery services Physical therapy Home health services.

question

Reviewing labs for a pt. who has schizophrenia and is taking clozapine. Which values are contraindications for receiving clozapine?

answer

WBC 2500/mm3

question

Collecting a health hx from a pt. who is taking paroxetine for depression. The pt. is also taking herbal supplements. Which supplement has an adverse interaction with paroxetine?

answer

St. John's wort

question

nursing care plan for pts who have depressive disorders. Statements that indicates an understanding of the teaching?

answer

"I will update the plan of care as a client's manifestations of depression change".

question

A pt. is behaving in a way suggestive of dependent personality disorder. Behaviors that are consistent with this condition?

answer

The client needs excessive external input to make everyday decisions.

question

Child taking methylphenidate should be monitored for which adverse effect?

answer

Tachycardia

question

Pt. with antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Behavior that indicates effectiveness of the therapy?

answer

Refrains from manipulating others to earn dining-room privileges.

question

Pt. with generalized anxiety disorder. At which level of anxiety should the nurse plan to teach the client relaxation techniques?

answer

Mild

question

Nurse overhears another staff member make derogatory comments to the client. Appropriate action?

answer

Report the occurrence to the charge nurse.

question

Caring for a pt. who has attempted suicide and has alcohol use disorder. Statement that indicates that the pt. is using a positive coping mechanism?

answer

"I will attend daily group therapy sessions to practice relaxation techniques."

question

Creating a plan of care for a pt. who has been placed in seclusion after threatening to harm others on the unit. Interventions to be included in the plan?

answer

Renew the prescription for the client every 4 hrs.

question

Planning care for a pt. who has depression and has made frequent suicide attempts. which statements indicates the pt. has a decreased risk for suicide.

answer

"It is easier to talk about my feelings now.

question

Routine labs for several pts. who are taking lithium carbonate. Pt. that should be further assessed for findings indicating lithium toxicity?

answer

A client who has a sodium level of 28 mEq/L

question

Expected findings for bulimia nervosa.

answer

tooth erosion.

question

Planning care for a preschool-age child who has ADHD. Which interventions should be identified as the priority?

answer

Remove unnecessary equipment from the child's surroundings.

question

Reviewing the chart of a pt. who has dissociative amnesia. Which findings should the nurse expect?

answer

The client was seriously injured while under the influence of alcohol

question

Recent diagnosis of Alzheimer's disease. The pt's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first?

answer

Frequently misplaces objects

question

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

answer

Use a therapeutic holding technique

question

Assessing 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

The client has COPD

question

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

answer

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

question

PT. with bipolar disorder is placed in a room with a client who has severe depression. The pt. with depression reports, "That man in my room never sleeps and he keeps me up, too." Appropriate action by the nurse.

answer

Move the client who bipolar disorder to a private room.

question

Planning care for a pt. who is to undergo electroconvulsive therapy (ECT). Which actions should be included in the plan of care?

answer

Monitor the client's cardiac rhythm during the procedure.

question

Obtaining a mental health hx for an older adult pt. Which of the following actions should the nurse plan to take?

answer

Interview the client in a private setting.

question

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

answer

"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

question

Planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

answer

Establish screening programs to identify at-risk clients.

question

Caring for a pt. who has bipolar disorder and reports that she stopped taking lithium 2 wks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the pt. to stop taking the medication?

answer

Hand tremors

question

A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lbs. Avavilable is chlorpromazine syrup 10mg/5mL. How many mL should the nurse administer? (Round to nearest whole #)

answer

14 mL

question

Planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority.

answer

Arrange one-to-one observation of the client.

question

Caring for a pt. with schizophrenia. Which places the pt. at the greatest risk for self-directed injurty or injuring others?

answer

Command hallucinations.

question

Facilitating a community meeting for acute care of clients. 1 pt. is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?

answer

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

question

home health nurse is assessing an older adult pt. whose sibling is the primary caregiver. Which findings indicates neglect?

answer

Inappropriate dress

question

Assessing a pt who has borderline personality disorder. Which of the following findings should the nurse expect?

answer

Emotional lability

question

Performing cognitive assessment to distinguish delirium from dementia in a pt. whose family reports episodes of confusion. Which of the following assessment findings supports the suspicion of delirium.

answer

easily distracted.

question

Caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?

answer

Shuffling gait

question

Pt. has anxiety disorder. Which statement by the pt. indicates successful use of guided imagery?

answer

"I imagine myself lying on a quiet beach when I start to feel anxious"

question

Assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue?

answer

Older children who are responsible for their younger siblings.

question

Pt. who is experiencing a panic attack. Which action should the nurse take?

answer

Assist the client with deep-breathing exercises.

question

Planning care for a pt. who has bipolar disorder and experiencing mania. Which intervention should the nurse include in the plan of care?

answer

Offer the client high-calorie finger foods frequently

question

Observes a pt. pushing on the locked unit door. Which statement should the nurse make?

answer

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

question

Charge nurse observes an AP slapping an older adult pt. After moving the pt to safety, which is the priority action?

answer

Determine if the client has been physically harmed.

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