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A nurse is performing a brief mental status examination for a client. To assess a client's ability to concentrate, the nurse should do which of the following? A. Point to 2 objects and ask the client to name them B. Ask the client to name the months of the year in reverse C. Say 3 words and ask the client to repeat them D. Ask the client to write a sentence - - correct ans- B. Ask the client to name the months of the year in reverse A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? A. Monitor the client's liver function B. Avoid giving the medication with food or milk C. Counsel the client regarding medication dependency D. Limit intake of foods containing tyramine - - correct ans- A. Monitor the client's liver function A nurse is admitting a client who has a hip fracture to the medical-surgical care unit. The client states, "I've never been in the hospital before, and I feel like I have a lot of anxiety." Which of the following responses should the nurse offer? A. "You're feeling anxious about being in the hospital for the first time." B. "Anxiety while in the hospital is a feeling many people experience." C. "Why do you think you feel anxious about being in the hospital?" D. "What activities do you enjoy when you're not in the hospital?" - - correct ans- A. "You're feeling anxious about being in the hospital for the first time."
A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? A. Chronic grief B. Uncomplicated grief C. Disenfranchised grief D. Delayed grief - - correct ans- C. Disenfranchised grief A nurse in a mental health clinic is caring for a client who has bipolar disorder and states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication? A. "You might feel good now, but what about when you get depressed?" B. "Why do you think you like feeling manic?" C. "You feel better when you don't take your medication?" D. "What do you think your provider will say about missing your medication?" - - correct ans- C. "You feel better when you don't take your medication?" A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? A. Discourage the client from taking naps during the day. B. Allow the client to choose which items of clothing to wear each day. C. Encourage the client to participate in group therapy. D. Provide the client frequently with high-calorie finger-foods. - - correct ans- D. Provide the client frequently with high-calorie finger-foods. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam? A. Decreased pulse rate
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgment C. Rapid change in personality D. Disturbances in perception - - correct ans- B. Impaired judgment A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors increases the client's risk of depression? A. The client is an only child. B. The client lives in an urban setting. C. The client is married. D. The client is female. - - correct ans- D. The client is female. A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection? A. "It sounds like you are concerned about your family's reaction." B. "What your family thinks isn't important; you need to be concerned about getting well." C. "It sounds like your family doesn't seem to understand you." D. "Many clients are concerned about the reactions of their families." - - correct ans- A. "It sounds like you are concerned about your family's reaction." A nurse is performing an admission assessment on a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect the client to report? (Select all that apply.) A. Difficulty sleeping for several weeks B. Inability to concentrate on simple tasks
C. Desire for sexual activity with multiple partners D. Absence of bathing for several days E. Lack of enjoyment from a long-time hobby of gardening - - correct ans- A. Difficulty sleeping for several weeks B. Inability to concentrate on simple tasks D. Absence of bathing for several days E. Lack of enjoyment from a long-time hobby of gardening A nurse is providing teaching to a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching? A. "If I fail to stop smoking after 12 weeks, I will have to try another product." B. "I will take the medication for 7 days before I try to stop smoking." C. "This medication will cause me to lose weight as I stop smoking." D. "I will take the medication after eating a meal." - - correct ans- D. "I will take the medication after eating a meal." A nurse is assessing a client with psychotic disorder who has a new prescription for haloperidol. The client is pacing in the hallway and states, "I can't seem to sit still." Which of the following extrapyramidal side effects is this client likely experiencing? A. Dystonia B. Parkinsonism C. Tardive dyskinesia D. Akathisia - - correct ans- D. Akathisia A client states, "I haven't seen my child for 2 weeks." The nurse responds, "Your child has not visited you for 2 weeks?" Which of the following communication techniques is the nurse using? A. Accepting
D. Contact an intensive outpatient program - - correct ans- D. Contact an intensive outpatient program A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing a staff member against another. Which of the following actions should the nurse take? A. Have the same staff members work with the client on a long-term basis B. Sit down and listen to the client's feelings about other staff members C. Explore with the client his use of clinging and distancing behaviors D. Arrange for the client to share complaints regarding staff members with the nursing supervisor - - correct ans- C. Explore with the client his use of clinging and distancing behaviors A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make? A. "Tell me how everyone wants to hurt you." B. "You must feel very frightened to think someone wants to hurt you." C. "No one here wants to kill you." D. "Who in particular do you think wants to kill you?" - - correct ans- B. "You must feel very frightened to think someone wants to hurt you." A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? A. "You can take this medication when needed." B. "The medication takes a few weeks to build up in your system." C. "You should plan to take this medication for 6 months." D. "Relapsing after withdrawing from this medication is rare." - - correct ans- B. "The medication takes a few weeks to build up in your system." A nurse in a long-term mental health facility is caring for a client who has a personality disorder.
The client has broken a unit rule, and phone privileges are being revoked consequently. The client asks the nurse, "Can I just make one more phone call?" Which of the following responses should the nurse make? A. "No, you can't. Go sit in your room." B. "Okay, if you promise to obey the rules for the rest of the day." C. "No, you can't. You have broken rules that apply to everyone." D. "You can make a single 5-minute phone call." - - correct ans- C. "No, you can't. You have broken rules that apply to everyone." A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions? A. Assign the client to a private room B. Ask the dietary department to provide the client with finger foods C. Place the client in 1-on-1 observation D. Keep the door closed to the client's room - - correct ans- C. Place the client in 1-on- 1 observation A nurse is caring for a client who has chronic alcohol use disorder and claims that her family is exaggerating the problem. The nurse should identify this behavior as which of the following defense mechanisms? A. Denial B. Introjection C. Regression D. Rationalization - - correct ans- A. Denial A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members
D. Suppression - - correct ans- C. Regression A nurse is caring for a client who has Alzheimer's disease. The client's adult son states the client has begun wandering away from her home. Which of the following responses should the nurse offer? A. "You should plan to move your mother into your home soon." B. "Place a complex lock at the top of each door that leads outside." C. "It is time to place your mother in a long-term care facility." D. "Have you reminded your mother about the dangers of wandering away from home?" - correct ans- B. "Place a complex lock at the top of each door that leads outside." A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. Which of the following findings should the nurse expect? A. Increased arousal B. Arrhythmias C. Confusion D. Esophageal pain - - correct ans- C. Confusion A nurse is preparing to meet with a client who has borderline personality disorder. Which of the following actions should the nurse plan to take during the working phase of the therapeutic relationship? A. Introduce the concept of client confidentiality B. Establish goals with the client C. Define the roles of the nurse and client D. Facilitate a change in the client's behavior - - correct ans- D. Facilitate a change in the client's behavior A nurse is interviewing a client who has anorexia nervosa. Which of the following findings should the nurse expect?
A. Poor personal hygiene habits B. Strenuous exercise regimen C. Grandiose behaviors D. Intense fear of death - - correct ans- B. Strenuous exercise regimen A nurse is caring for a client who is receiving treatment at an inpatient alcohol treatment facility. Which of the following actions should the nurse identify as an example of an intentional tort? A. Administering an incorrect dose of benzodiazepine B. Informing the client's family member of the admission without the client's knowledge C. Informing the client that an injection will be administered if the client remains agitated D. Failing to recognize suicide risk, resulting in the client's death - - correct ans- C. Informing the client that an injection will be administered if the client remains agitated A nurse is caring for a client who has schizophrenia and started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications? A. Neuroleptic malignant syndrome B. Akathisia C. Anticholinergic toxicity D. Opisthotonos - - correct ans- B. Akathisia A nurse is planning care for a client who has vegetative signs of depression. Which of the following actions should the nurse include in the plan? A. Limit snacking between meals B. Schedule regular naptimes during the day C. Weigh the client monthly
D. "Bleeding during my daughter's periods will increase." - - correct ans- B. "It is important for my daughter to have regular dental checkups."
caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? A. Talk to the client from 2 arm-lengths away B. Obtain assistance to restrain the client for safety C. Firmly state to the client that morning care will be performed D. Call the provider to request a prescription for an antipsychotic medication - - correct ans- A. Talk to the client from 2 arm-lengths away A nurse is providing teaching to the partner of a client who has alcohol use disorder. Which of the following statements by the partner indicates an understanding of the teaching? A. "Having 6 beers in 2 hours is considered too much." B. "My partner is not at risk for cancer due to alcohol consumption." C. "My partner should consume no more than 20 drinks of alcohol in a week." D. "There is no genetic risk with abuse alcohol." - - correct ans- A. "Having 6 beers in 2 hours is considered too much." A nurse is creating a plan of care for a client who has Alzheimer's disease with moderate cognitive decline. Which of the following interventions should the nurse include to orient the client to the present? A. Discourage the client from reminiscing about the past. B. Overlook the client's frustration with communication. C. Talk with the client about scheduled daily activities. D. Present multiple options when offering the client choices. - - correct ans- C. Talk with the client about scheduled daily activities. A nurse is caring for a client who reports that the television set in the room is really a 2-way radio and states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse offer?
D. The client demonstrates reorganization of behavior. - - correct ans- A. The death was a result of violence. preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregiver. Which of the following actions should the nurse take? A. Make sure the caregiver is present when interviewing the client B. Document how the caregiver responds when told that the client looks neglected C. Ask the client why she refuses to eat the caregiver's food D. Identify sources of stress for the caregiver - - correct ans- D. Identify sources of stress for the caregiver A nurse is interviewing a client who has a new diagnosis of major depression. Which of the following questions is the nurse's priority? A. "Have you thought about hurting yourself?" B. "What has been troubling you?" C. "Do you have anyone who can offer you support?" D. "When did you start feeling bad?" - - correct ans- A. "Have you thought about hurting yourself?" A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching? A. "You should have your white blood cell count checked once per week for 6 months." B. "You should check yourself every 3 days for weight loss." C. "You might experience frequent loose stools." D. "You might experience ringing in your ears." - - correct ans- A. "You should have your white blood cell count checked once per week for 6 months."
A nurse is A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for this therapy? A. The client will gain increased self-esteem. B. The client will maintain orientation to place and time. C. The client will independently perform ADLs. D. The client will achieve optimal sensory stimulation. - - correct ans- A nurse in a health clinic is providing teaching to a client about binge eating disorder. Which of the following client statements indicates an understanding of the teaching? A. "This problem is caused by a slow metabolism." B. "The abdominal pain I often have is due to the amount of food that I eat." C. "Most of my weight gain is water weight." D. "At least I do not need to worry about being physically ill." - - correct ans- A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety? A. Varenicline B. Clonidine C. Buprenorphine D. Disulfiram - - correct ans- A nurse in a mental health clinic is beginning a counseling session with a client who is having difficulties in a personal relationship. The client states that she does not want to talk at all today. Which of the following responses should the nurse make? A. "Why don't you want to talk today? We have talked several times before." B. "I think you should take a moment to collect your thoughts. Then, you need to talk."
A nurse is a client assessing who has binge-eating disorder. Which of the following findings should the nurse expect? A. Amenorrhea B. Abdominal pain C. Restricted caloric intake D. Frequent use of laxatives - - correct ans- B. Abdominal pain A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take? A. Speak to the client in a calm voice B. Leave the client alone to regain control C. Encourage the client to express her feelings D. Place the client in restraints - - correct ans- A nurse is assessing the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills - - correct ans- A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? A. Assign the client several tasks at the same time B. Maintain a low-stimulation environment C. Advise family to visit frequently as a group
D. Encourage the client to make choices regarding care - - correct ans- B. Maintain a lowstimulation environment A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I can't control them." Which of the following responses should the nurse provide? A. "Why do you think you are experiencing these behaviors of binges and vomiting?" B. "Are other students in your dorm also experiencing this behavior?" C. "You are feeling helpless about changing this behavior?" D. "You know you must stop because you are endangering your health." - - correct ans- C. "You are feeling helpless about changing this behavior?" A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration - - correct ans- D. Maintaining adequate hydration A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine hand tremors in both hands D. Serum lithium level of 1.1 mEq/L - - correct ans- A. Report of nausea with frequent episodes of emesis assessing who has conduct disorder. Which of the following findings should
