A nurse on a mental health unit is assisting with the plan of care
for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
a. weigh the client at night prior to bedtime
b. offer liquid supplements to the client
c. encourage the client to gain 2.3 kg (5 lb) per week
d. observe the client for up to 30 min after meals
A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and begins throwing objects at staff and other clients. After calling for assistance, which of the following actions should the nurse take next?
a. obtain a prescription for mechanical restraints
b. place the client in a monitored seclusion room
c. tell the client calmy to sit down
d. administer diazepam intramuscularly
A nurse is caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse report to the charge nurse?
a. a client who has schizophrenia is communicating using echolalia
b. a client who has depression is exhibiting anergia
c. a client who is manic has been pacing the unit for several hours
d. a client who has a phobia is using thought stopping
A nurse is collecting data from a client who is taking valproic acid for treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider?
a. drowsiness
b. nausea and vomiting
c. constipation
d. bleeding gums
A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next?
a. discuss information about the dilemma with the client's provider
b. determine the benefits and consequences of respecting the client's medical decisions
c. reflect on the effect of ethical theories on the nurse's personal values
d. develop a plan that balances both the nurse's values and the client's medical decisions
A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions should the nurse take to demonstrate modeling as a behavioral intervention strategy?
a. setting a time limit between episodes of hand hygiene
b. reminding the client to shout "stop" each time she has an urge to perform hand hygiene
c. demonstrating performing hand hygiene at appropriate times
d. instructing the client to practice muscle relaxation when she has the urge to perform hand hygiene
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take when caring for this client?
a. persuade the client to demonstrate acceptable behavior
b. avoid talking about the client's past display of unacceptable behavior
c. use countertransference to develop the therapeutic relationship
d. remind the client of consequences for unacceptable behavior
A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the following interventions should the nurse include in the plan?
a. restrict the client's sodium intake
b. encourage the client to eat three large meals per day
c. weigh the client weekly
d. observe the client for 1 hr after he eats
A nurse is collecting data from a client whose home was destroyed by a fire. Which of the following responses should the nurse make first?
a. "Are you experiencing feeling of hopelessness?"
b. "Is there someone I can call for you?"
c. "It might be helpful for you to attend a support group?"
d. "Now is a good time for you to use relaxation breathing."
A nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use disorder. Which of the following statements by the parent should the nurse identify as indicating an understanding of the teaching?
a. "I should be alert for weight gain in my child."
b. "I can tell my child is using amphetamines because he is drowsy."
c. "Dilated pupils are a sign my child is using amphetamines."
d. "Memory loss can indicate that my child is using amphetamines."
A nurse is collecting data from a client who has agoraphobia. The nurse should identify that which of the following situations will increase the client's anxiety?
a. traveling in an airplane
b. entering a walk-in closet
c. taking a bath
d. picking up a soiled tissue
A nurse is monitoring communication between a client who has alcohol use disorder and her partner. Which of the following communication patterns of the client's partner should the nurse identify as being effective?
a. "I can never talk to you because you are always drunk."
b. "I become very angry when you get drunk."
c. "Because of your drinking, we can't have guests in our home."
d. "Don't be mad at the kids. It was my fault that the dishes did not get done."
A nurse is preparing to administer lithium 450 mg PO to a client who has bipolar disorder. Available is lithium 150 mg capsules. How many capsules should the nurse administer? (Round the answer to the nearest while number. Use a leading zero if it applies. Do not use a trailing zero.)
A nurse is collecting data from a client who uses alcohol "to cope with stress." Which of the following questions should the nurse ask?
a. "Do you see how your alcohol consumption affects your employment?"
b. "Is your partner affected by your alcohol consumption?"
c. "What daily activities are disrupted because of your alcohol consumption?"
d. "Would you agree that stressful times in your life lead to increased alcohol consumption?"
A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make?
a. "If you can control your actions this week, I'll talk to your parents about extending your curfew."
b. "Have you considered participating in a sport to help you control your aggression?"
c. "If you become aggressive, your parents will take away privileges."
d. You're hurting others. Do you understand why that's wrong?"
A nurse on an inpatient mental health unit is supervising a group of clients in the unit's dayroom. The nurse fails to responds to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable?
a. battery
b. nonmaleficence
c. Negligence
d. Boundary violation
A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findings should the nurse withhold the client's medications and notify the provider?
-BP 102/50, resp 18, HR 100, temp 37.8C (100F), SpO2 96%, weight 77 kg, height 177.8cm
-WBC 3000/mm^3, Hgb 14 g/dL, Hct 42%, platelets 150,000/mm^3, Fasting BG 107, Clozapine 200 mg PO daily, Tramadol 50 mg PO Q6HR, Diphenhydramine 50 mg PO Q4HR
a. fasting blood glucose
b. temperature
c. WBC count
d. Heart rate
A nurse on a mental health unit is caring for four clients how have schizophrenia. Which of the following clients should the nurse see first?
a. the client who has anergia
b. the client who demonstrates ambivalence
c. the client who demonstrates concrete thinking
d. the client who is experiencing command hallucinations
A nurse is reinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make?
a. "You should exercise immediately prior to going to sleep."
b. "You should listen to music when you feel stress."
c. "Take a 1-hour nap every afternoon."
d. "You should stop drinking caffeine immediately."
A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following actions should the nurse take?
a. keep the client lying in a supine position for 2 hr
b. administer oxycodone/acetaminophen to the client
c. keep the client NPO for 6 hr
d. administer oxygen to the client
A nurse is caring for a client who has psychiatric somatic symptom disorder. Which of the following actions should the nurse take?
a. obtain the client's vital signs each time the client reports physical illness
b. remind the client that his symptoms are not real
c. encourage the client to examine how his illness behavior affects his family
d. provide adequate time for the client to describe his symptoms
A nurse is caring for a client who recently lost his child in a motor-vehicle crash. the client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask?
a. "Are there times when you feel more upset than others?"
b. "Have you had any thoughts of harming yourself?"
c. "What type of support system do you currently have?"
d. "During difficult times in the past, what did you do to cope?"
A nurse is caring for a client who has dementia. Which of the following actions should the nurse take?
a. keep the client's room dark at night
b. alternate the client's caregivers on a routine basis
c. stand in front of the client when speaking
d. remove personal belongings from the client's room
A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe?
a. Flumazenil
b. Vitamin K
c. Acetylcysteine
d. Naloxone
A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findings should the nurse identify as manifestations of bulimia nervosa? (select all that apply.)
a. tooth erosion
b. hand calluses
c. lanugo
d. amenorrhea
e. hypokalemia
A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider?
a. potassium 4.0 mEq/L
b. lithium 0.9 mEq/L
c. BUN 12 mg/dL
d. Sodium 132 mEq/L
A nurse is collecting data from a client who has delirium. The nurse should identify which of the following conditions as a predisposing factor for delirium?
a. Hepatic failure
b. Chronic alcohol use
c. hypertension
d. fluid volume overload
A nurse is caring for a client who state, "This has been the worst day of my life." Which of the following responses should the nurse make?
a. "You should focus on positive thoughts."
b. "Everybody has a bad day now and then."
c. "Tomorrow will be a better day."
d. "Tell me about your day."
A nurse is assisting with the admission of a client to an acute care mental health facility. Which of the following activities should the nurse plan for the working phase of the therapeutic relationship?
a. define the specific responsibilities of the client and of the nurse
b. assist the client to establish mutual goals
c. evaluate the client's progress toward meeting his goals
d. discuss how the client can incorporate new strategies into his daily life
A nurse is caring for four clients who are displaying the use of defense mechanisms. Which of the following clients should the nurse identify as using a maladaptive defense mechanism?
a. a client who has multiple sclerosis stops taking her medication and says her diagnosis is wrong
b. an adolescent client who has difficulty with reading becomes a star athlete.
c. a client admires a high school principal who separated two students who were having a fight
d. a client who has a gambling disorder volunteers in a head start program
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