A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?
answer
A client was administered one-half of the prescribed dose of medication
an incident report is a recording of any occurrence that does not meet the standard of care. the nurse should report medication errors using the facility's incident or occurrence form
question
a nurse is caring for a group of clients. Which of the following findings is the nurse required to report?
answer
A client who has borderline personality disorder threatened to harm their roommate
s/s of BPD include interpersonal relationships accompanied by threats and other-directed violence. while it is important for the nurse to maintain the pts confidentiality on occasions when another individuals like might be in danger, the nurse is required by law to report it to authorities
question
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?
answer
The client will refrain from self-mutilation
the greatest risk to the pt is injury to self and others. therefore, the priority goal is for the pt to refrain from self-mutilation
question
a nurse is discussing the home care of a client who has advanced Alzheimer's disease with he client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommended to the caregiver?
answer
Respite care
respirte care programs allow the pt to stay ina nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves
question
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?
answer
Talk with the client about activities they enjoyed with their partner
talking about positive experiences can help distract the pt from their disorientation
question
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?
answer
Clang association
the nurse should document that the pts speech uses clang associations which often rhyme or contain a string of words that can have a similar sound
question
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
Anhedonia
neg symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than pos symptoms. these symptoms develop over time. examples of neg symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities and thought blocking
question
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
answer
Change the dressing of a client who has borderline personality disorder and superficial self-inflicted wounds
a pt who has borderline personality disorder is at risk for self-mutilation such as cutting, self-inflicted wounds, scratching or picking at wounds. it is within the LPNs scope of practice to change the dressing cleanse the wound, and collect data regarding the healing of the wound
question
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?
answer
Aggression toward animals
the nurse should identify that aggression toward people and animals is an expected characteristic of a child who has conduct disorder
question
A nurse in a mental health clinic is planning car for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?
answer
Instruct the client to avoid driving during initial therapy
the greatest risk to the pt is injury resulting from drowsiness or dizziness. therefore the nurses priority intervention is to instruct the pt to avoid activities that require mental alertness during initial med therapy
question
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempt to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?
answer
Do not administer the lorazepam
pts who are in a facility d/t an involuntary admission retain the right to refuse tx. therefore, the nurse should hold the med and document the pts refusal
question
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?
answer
The client reports command hallucinations
the nurse should identify that command hallucinations can indicate a potential psychiatric emergency for a pt who has schizophrenia. command hallucinations can direct the pt to harm themselves or others
question
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?
answer
Emotional lability
it is the rapid transition from one emotion to another an is a primary feature of borderline personality disorder. pts who have BPD react to situations with emotional responses that are out of proportion to the circumstances
question
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
The client needs excessive external input to make everyday decisions
pts who have dependent personality disorder need excessive input from others to make everyday decisions
question
A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?
answer
Inappropriate dress
clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator of neglect
question
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
Set realistic limits on the clients behavior
pts who have antisocial personality disorder can seem to be in control of their behavior, but are manipulative and impulsive and can suddenly become aggressive and assaultive. the nurse should establish clear limits on specific aggressive and demanding behaviors
question
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
Gather supplies for endotracheal intubation
the nurse should gather supplies for endotrachial intubation because an expected findings of an unresponsive pt who has alcohol toxicity is resp depression
question
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse administer?
answer
14
question
A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?
answer
Encourage frequent rest periods throughout the day
a pt who is experiencing acute mania is at risk for sleep disturbances and might go for extended periods of time w/o sleep. encouraging periods of rest throughout the day can limit the risk of exhaistion
question
A nurse is reviewing routine laboratory values for several clients who re taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?
answer
A client who has a sodium level of 128 mEq/L
a sodium level of 128 mEq/L should alert the nurse that the pt is at risk for lithium toxicity bc renal excretion of lithium is decreased in the presence of a low Na level
question
a nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment?
answer
Orthostatic hypotension
low weight, e imbalances, starvation, and dehydration cause orthostatic hypotension
question
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
"If you do my homework for me, I won't bother to for the rest of the day."
this is an example of manipulative behavior. it is an ex of this when the family member uses a behavior to get what they desire rather than directly asking for what they want
question
A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?
answer
"In the event a client threatens to harm others, medications can be administered without consent"
the charge nurse should inform the participants that their primary commitment is to the pt and their priority is always to advocate for and protect their health and safety. during an emergency situation, if the pt is threatening harm to self or others, meds can be admin w/o pts consent and w/o a court order
question
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. which of the following actions should the nurse take?
answer
Ask the family member is they have any thoughts or questions about the treatment plan
this action involves the family member and allows them a venue to communicate about the pts medication tx plan
question
A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. which of the following is the priority action by the nurse?
answer
Provide frequent high-calorie snacks
the priority action the nurse should take when using Maslow's hierarchy of needs is to meet the pts need for adequate nutrition. therefore providing high-calorie snacks is the priority action for the nurse to take
question
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer fist?
answer
Diazepam 5 mg IV bolus
the greatest risk to the pt who is experiencing alcohol withdrawal is seizures, an elevated HR, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vital signs and decrease the intensity or withdrawal manifestations
question
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk or complicated grief?
answer
"I feel so empty without my wife that it's hard to get p every morning."
the nurse should identify that when a pt has difficulty carrying on normal activities following a loss, this is an indication that there is a risk for complicated grief
question
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. he nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?
answer
Hand tremors
fine hand tremors are an expected adverse effect of lithium and can interfere with performance of ADLs causing the pt to stop taking the medication
question
A nurse is teaching a client who has a depressive disorder about fluoxetine. which of the following information should the nurse include in the teaching?
answer
"You might experience difficulties with sexual functioning while taking this medication."
fluoxetine is a SSRI that can cause sexual dysfunction such as anorgasmia and impotence. the nurse should instruc the pt to notify MD if SD occurs
question
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?
answer
Ask the client what the voices are saying
it is important for the nurse to ask the pt directly about the hallucinations to determine if the pt or others are at risk for injury
question
A nurse is admitting a client 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
the nurse should encourage this to maintain hydration
question
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. which of the following actions should the nurse take?
answer
Assess the client for evidence of a perceptual disturbance
the nurse should do this to determine if the pt is hallucinating or misperceiving external stimuli, also known as experiencing illusions
question
A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benzotropine 2 mg IM
answer
Shuffling gait
benztropine is used to treat parkinsonism manifestation such as shuffling gait
question
During a client's initial interview in a mental health inpatient 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
The client is interested in what the nurse is saying
the pts posture and eye contact demonstrates an interest int he interview and what the nurse is saying
question
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?
answer
The client reports an inability to breathe easily
serious adverse effects, such as HF, myocarditis, and PE are associated with clozapine. when using the greatest firs framework, the nurse should identify that the greatest risk to the pt is dyspnea, which is a manifestation of resp or cardiac alterations, and should be reported to the provider
question
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?
answer
Total body fat 8.7%
the nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. the nurse should report this finding to the provider
question
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?
answer
Report the occurrence to the charge nurse
it is the charge nurse and nurse manager's responsibility to confront the staff member about the derogatory comments made to the pt
question
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 for suicide?
answer
"It is easier to talk about my feelings now."
when pts express their feelings, this indicates a positive tx outcome
question
A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?
answer
Attending a relapse prevention group several times each week
the nurse should identify that the most effective strategy for relapse prevention is a 12 step program such as AA
question
A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depresion and a blood pressure of 210/105 mm Hg and a temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first?
answer
Determine the clients prescribed medication regimen
the first action of the nurse should be, using the nursing process, is to assess the pt. by determining the pts prescribed meds, the nurse can determine the cause of htn such as the pt taking an MAOI to treat depression. these meds can precipitate a htn crisis if consumed with tyramine containing foods, including wine
question
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?
answer
Substance use disorder
the nurse should identify that pts who have substance use disorder are at an increased risk for the development of depressive disorders
question
A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication?
answer
"I should eat a regular diet with normal amounts of salt and fluids."
the nurse should identify that this statement indicates that the pt understands the teaching bc normal levels of Na and fluid need to be maintained to ensure adequate excretions of lithium. if Na levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity
question
A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching?
answer
Avoid looking directly at the light during treatment.
light therapy, or phototherapy can cause sensitivity to light. to minimize this effect, the pt should avoid looking directly at the light
question
A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?
answer
Remove unnecessary equipment from the child's surroundings
the greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. therefore the priority intervention is to remove unnecessary equipment from the child's surrounding
question
A nurse is 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
the greatest risk to the pt is self-injury. therefore, the priority nursing intervention is 1:1 observation to promote pt safety
question
a nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks thenurse about this medication. Which of the following responses should the nurse make?
answer
"Succinylcholine is given to reduce muscle movement during therapy."
it is a muscle-paralyzing agent that will decrease muscle movement during the procedure so the pt is less likely to be injured
question
A nurse is planning care for a client who has schizophrenia and reports auditory hallucination. Which of the following interventions should the nurse include in the plan?
answer
Promote the use of music to compete with the client's auditory hallucinations
competing reality-based stimulation such as the use of music or televisions during auditory hallucinations can assist in limiting the effect the hallucination on the pts stress level
question
A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?
answer
Interview the client in a private setting
the nurse should interview pts in a private place when asking questions regarding pt health
question
A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?
answer
The client recently lost a grandparent in a motor vehicle crash
the pt experiences a situational crisis when an unexpected event occurs
question
A nurse in a n outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. the client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine?
answer
St. John's wort
this is an herbal preparation that decreases the reuptake of serotonin. the nurse should advise the pt that taking st. john wort with another med that also inhibits the reuptake of serotonin, such as paroxetine places the pt at risk for serotonin syndrome
question
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism'?
answer
"I am able to go to work every day, so I don't have a problem."
by insisting that their drinking is not a problem bc they can go to work every day, the pt is suing the defense mechanism of denial. this allows the pt to ignore the existence of their substance use disorder
question
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?
answer
Hypertension
cocaine is a stimulant that increases BP. it also increases HR, body temp, energy levels, and metabolism
question
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?
answer
Attention to body language
use of active listening involves identifying verbal and nonverbal communication by the pt, which includes attention to body language
question
A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn they do not respond. Which of the following actions should the nurse take before repeating the request to the client?
answer
Allow the client time to formulate an answer
slowed response time is common who have depression. the nurse should allow the pt time to comprehend and formulate an answer to the question
question
A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.)
answer
- Feelings of hopelessness
- Anhedonia
- Flat facial expression
the nurse should document feelings of hopelessness as a clinical manifestation of MDD. the nurse should document the inability to experience pleasure as a S/s of MDD. the nurse should document a flat facial expression as a clinical S/S of MDD.
question
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
Dark urine
the greatest risk for the child is liver damage from atomoxetine which can progress to liver failure and death.
question
a nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?
answer
Refrains from manipulating others to earn dining room privileges
the goal of operant conditioning is to provide positive reinforcement in return for a desired behavior. refraining from manipulative behavior is a desired response
question
A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client'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
according to EBP the nurse should identify that mild cognitive impairment, such as frequently misplacing objects is one of the first manifestations expected to occur for a pt who has alzhemiers disease
question
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
answer
A client who is taking lamotrigine and has developed a rash
lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. the nurse should identify that a rash is a potentially life threatening adverse effect of the medication and report this finding immediately
question
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?
answer
"It is not uncommon to feel angry toward yourself or others."
feelings of blame and anger towards oneself or others are an expected reaction when a pt is experiencing a loss
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