NU250 NCLEX Q – Flashcards
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A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?
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"I am concerned about you. Are you now or have you ever been abused?"
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A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion?
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Gathering subjective and objective assessment from the caregiver and the client
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Which are characteristics of the termination stage of group development? Select all that apply.
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*1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with each other. 5. Some structuring of group norms, roles, and responsibilities takes place. *6. The group explores members' feelings about the group and the impending separation
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Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
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* 1. Monitor vital signs. 2. Maintain NPO status. * 3. Provide a safe environment. * 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. * 6.Provide reality orientation as appropriate
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The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
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Hypertension, changes in level of consciousness, hallucinations
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A 45-year-old client states that he used to drink a cocktail nightly after work and also had a drink with his meal. Now he has two drinks before dinner and two or three more drinks during his meal. As the client continues to describe his alcohol intake, the nurse discovers that he also has added a couple of drinks at night to help him sleep. Which is the most accurate assessment of his alcohol consumption?
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Tolerance
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Which is the best approach for the nurse to use in crisis counseling
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Active, with focus on the current situation
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The nurse is monitoring a woman with a diagnosis of depression. Which behavior, if observed by the nurse, indicates that suicide precautions should be implemented for this client?
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The woman asks to meet with a lawyer to take care of unfinished business.
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The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
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Observing rigid rules and regulations
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A nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?
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Assess the client for organic causes of the paralysis.
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A nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care?
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Reward the client when a desired behavior is performed.
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A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for the possibility that which will occur?
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The client will employ new coping methods that will resolve the problem.
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A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which best response should the nurse make?
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"You haven't had an appetite at all?"
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The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a plan. An expected outcome of this plan of care would be that the client does which?
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Denies suicidal ideation and identifies options to deal with stressors
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A mental health nurse asks a nurse orientee to describe the underlying pathophysiology associated with acts of compulsion, such as repeated hand washing, performed by clients with obsessive-compulsive disorder (OCD). The nurse determines that the orientee understands this disorder if the orientee identifies which characteristic of the client?
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Unconsciously controlling unpleasant thoughts or feelings
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A client who has a history of being sexually assaulted is admitted to a psychiatric unit for self-mutilation. She is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism?
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Regression
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The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter stashes food, eats all the foods that make her hyperactive, and hangs out with the "wrong crowd." In helping the mother prepare for her daughter's discharge, what instruction should the nurse provide
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Restrict the amount of chocolate and caffeine products in the home.
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The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse?
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"What do you find difficult about this situation?"
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A clinic nurse is monitoring a client with anorexia nervosa. Which statement, if made by a client, should indicate to the nurse that treatment has been effective?
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"My friends and I went out to lunch today."
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A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?
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"You seem very distressed over learning you have asthma."
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A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the day before ECT includes ensuring that the client follows which guideline?
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Reports to the clinic for blood draws and an electrocardiogram (ECG)
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Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
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* 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. *3. Assist the client in identifying ways of setting limits on personal behaviors. *4.Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. *6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
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Which is the primary goal of crisis intervention therapy?
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Assist the client in returning to the level of pre-crisis functioning.
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A nurse is caring for a suicidal client. What is the appropriate nursing intervention in dealing with this client?
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Provide authority, action, and participation.
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The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply.
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* 1. Dental decay 2. Moist oily skin *3. Loss of tooth enamel *4. Electrolyte imbalances 5. Body weight well below ideal range
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A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize that which symptoms or behaviors require immediate intervention?
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Constant physical activity and poor oral intake
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A client who has a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?
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Lack of naturally occurring endorphins
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The nurse should identify which best goal for a client experiencing hallucinations?
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Facilitate the client's awareness that the hallucination is not the reality of the world.
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The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply.
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1. Provide a warm approach to the client. * 2. Ask permission before touching the client. * 3. Eliminate physical contact with the client. * 4. Defuse any anger or verbal attacks with a nondefensive stance. * 5. Use simple and clear language when communicating with the client.
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A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship?
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Termination
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A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which is the least realistic goal for this client?
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The client will stop blaming himself for the lack of insurance
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The nurse is planning relapse prevention information for a client with schizophrenia who is being discharged. The nurse understands that it is important to ensure which primary intervention in the plan whenever possible?
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Including the client's support system in the teaching
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The nurse is preparing a care plan for a client exhibiting negative symptoms of schizophrenia. Which are indicative of negative symptoms? Select all that apply.
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* 1. Short attention span 2. Delusional thoughts 3. Inappropriate body movements 4. Loose associations of thought * 5. Limited ability to communicate verbally
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A client with a history of panic disorder comes to the emergency department and states to the nurse: "Please help me—I think I'm having a heart attack." What is the priority nursing action?
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Assess the client's vital signs
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The nurse understands that schizophrenia hinders a client's cognitive ability to appropriately process data from external stimuli. This dysfunctional processing can result in which problem?
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Delusional beliefs
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A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention?
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Turn off the television
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A nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?
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Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis
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The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which is the appropriate nursing intervention?
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Offer to assist the client to an examination room until the HCP is notified.
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The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client?
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Lack of ability to cope effectively
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A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record?
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The client has a flat affect
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The nurse is performing a mental status examination on a client, and the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." Which interpretation by the nurse is appropriate?
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Speech is illogical and loosely associated.
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The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk?
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"Do you have a plan to commit suicide?"
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Which best describes the purpose of behavioral therapy?
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Fosters positive behavioral change
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A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern?
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"Do you feel afraid that people are trying to hurt you?"
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The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response?
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Inappropriate affect
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A nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if which is assessed
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Client has an immediate plan for a suicide attempt.
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The nurse caring for a client diagnosed with schizophrenia should include which interventions into the plan of care to assist in managing the client's concrete thinking?
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Present verbal instructions regarding expectations in single, simple commands
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The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development?
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Acknowledging the contributions of each group member
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A small rural community has experienced a hurricane that has destroyed 65% of the homes and businesses in the area. Community mental health teams recognize that in the immediate post-disaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action?
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Station mental health professionals at established assistance centers
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The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy (ECT). Which problem is a priority for this client?
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Risk for aspiration
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A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which roommate choice is least appropriate for this client?
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A client with pneumonia
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The nurse is planning to instruct a mental health client and his or her family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply
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1. Giving all medications just once per day * 2. Including the family in the medication planning process * 3. Working with the psychiatrist to find the right medication at the right dose * 4. Providing the client with the injectable, long-acting form of the medication if available * 5. Working with the psychiatrist to find the medication that provides the least side effects for the client
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An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which interventions should the nurse include? Select all that apply
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* 1. Assisting the client to identify and test negative cognition * 2. Assisting the client to participate in the treatment process * 3. Assisting the client to develop alternative thinking patterns * 4. Assisting the client to rehearse new cognitive and behavioral responses 5. Assisting the client with the administration of antidepressant medications 6. Assisting the client's family to participate in group therapy on a regular basis
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The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which would be unrealistic as a short-term initial goal for this client?
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The client will resolve feelings of fear and anxiety related to the rape trauma
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The psychiatric home care nurse visits a client with a phobia who experiences panic attacks. The nurse teaches the client to use paradoxical intention and employs which method to teach the client this form of therapy?
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Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor
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The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, knowing that which is the maximum number of group members that can be included?
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8
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A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?
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"I hear what you are saying, but I don't share your belief."
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The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?
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"Do you know that enabling creates codependency? Isn't viewing his failure as yours significant?"
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A nurse is developing a plan of care for the client who is upset following the loss of a job. The client is verbalizing concerns regarding the ability to meet financial obligations. Which is the appropriate client problem?
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Inability to meet role expectations
