A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms, speaking inappropriately, and giggling.
47. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms, speaking inappropriately, and giggling. Which of the following actions should the nurse take?
A. Lead the client outside for a walk.
B. Have the client return to her room to read a book.
C. Take the client to the day room to watch a movie with other clients.
D. Tell the client there will be negative consequences for her behavior.
48. A nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner 6 months ago. Which of the following actions should the nurse take?
A. Explain that it can take a year or more to learn to live with a loss.
B. Suggest that the client avoid social interactions that remind her of her partner.
C. Discourage the client from reliving the events surrounding her loss.
D. Direct the client to maintain an unstructured daily routine.
49. A nurse is assessing the boundaries of a client’s family. One of the family members says to the client, “I know exactly what you’re thinking right now.” The nurse should recognize that the family member is displaying which of the following types of family boundaries?
A. Inconsistent
B. Rigid
C. Enmeshed
D. Clear
50. A nurse in an emergency department is caring for a client following a domestic dispute. The client states, “Nothing seems to go right for me and probably never will.” Which of the following statements should the nurse make?
A. “We will help get you through this. You’ll be fine.”
B. “Are you thinking about harming yourself?”
C. “What have you done to change your situation?”
D. “You should remove yourself from this situation now.”
51. Exhibit 1: Nurses’s Notes: Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, “It feels like my heart is jumping in my chest.”
Question: A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
A. Edema
B. Intake
C. Heart rhythm
D. Temperature
Exhibit 2: Graphic Results: BP 100/84 mm Hg, Pulse rate 58/min, Respiratory rate 16/min, Temperature 36.4 degrees C( 97.5 degrees F), SaO2 96%, BMI 16
Question: A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
A. Edema
B. Intake
C. Heart rhythm
D. Temperature
52. A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following?
A. Cardiac toxicity
B. Hypertensive crisis
C. Urinary retention
D. Serotonin syndrome
53. A nurse is interviewing a client who reports ongoing feelings of depression after the death of his 9 months ago. Which of the following actions should the nurse take?
A. Encourage the client to avoid discussing the events surrounding the siblings’s death.
B. Caution the client against feeling angry at the sibling.
C. Explain to the client that the duration of grief is highly variable and can last for years.
D. Recommend that the client participate in more solitary activities.
54. After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the following actions should the nurse take first?
A. Teach the client specific coping skills to handle stressful situations.
B. Assist the client to lower his anxiety level.
C. Involve the client in planning interventions.
D. Help the client identify social support.
55. A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching?
A. “If I cut myself, I can clean the wound with isopropyl alcohol.”
B. “I can wear my cologne on special occasions.”
C. “When I bake my favorite cookies, I can use pure vanilla extract for flavoring.”
D. “I can continue to eat aged cheeses and chocolate.”
56. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
A. Encourage the client to join group activities.
B. Provide detailed explanations to the client.
C. Administer methylphenidate to the client.
D. Dim the lights in the client’s room.
57. A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse include in the teaching?
A. A school-age child whose mother died 2 years ago talks about her in the present tense.
B. An adult who was sexually abused as a child is unable to remember the incident.
C. A student who is upset with her teacher writes a story about an excellent student.
D. A woman who has a health concern postpones a medical appointment until after a vacation.
58. A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse’s neighbor. The nurse should identify which of the following must occur when establishing a therapeutic nurse-client relationship?
A. The nurse maintains confidentiality unless the client’s safety is compromised.
B. The client regards the nurse as a friend.
C. The client sees the nurse as an authority figure.
D. The nurse seeks to spend extra time specifically with the client each day.
59. A nurse is providing teaching about lorazepam to a client who has an anxiety disorder. Which of the following statements should the nurse include in the teaching?
A. “You can take an extra dose of medication if you are feeling very anxious.”
B. “This medication might cause a decrease in your blood pressure.”
C. “This medication might cause you to hyperventilate.”
D. “Expect to have coughing episodes while taking this medication.”
60. A nurse is speaking to a former high school friend. The friend states, “I heard one of our high school teachers was admitted to your hospital. Is everything okay?” Which of the following responses should the nurse make?
A. “I recommend you contact the hospital to see if she has been admitted.”
B. “I think that you should contact the highschool for information about her.”
C. “I can only discuss the status of a client with the client’s family.”
D. “I cannot discuss the care of anyone who might be hospitalized in our facility.”
61. A nurse is caring for a client who has schizophrenia and is experiencing delusions. The client states, “I can feel worms crawling through my veins.” Which of the following types of delusions should the nurse document the client is experiencing?
A. Delusion of persecution
B. Erotomanic delusion
C. Delusion of reference
D. Somatic delusion
62. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify which of the following is a therapeutic effect of this medication?
A. Prevents the anxiety of abstinence
B. Reduces substance craving
C. Decreases the likelihood of seizures
D. Blocks aldehyde dehydrogenase
63. A nurse is caring for a client who is experiencing a panic level of anxiety in the dayroom. After instructing the client to perform deep breathing exercises, which of the following actions should the nurse take next?
A. Teach the client about physical manifestations of anxiety.
B. Discuss methods the client can use to cope with anxiety.
C. Take the client to an area with fewer distractions.
D. Encourage the client to discuss the events preceding the panic attack.
64. A nurse is caring for a client who was just placed in mechanical restraints. Which of the following actions should the nurse take?
A. Request that the provider provide an as-needed prescription for restraints.
B. Withhold food and drink until the restraints are removed from the client.
C. Offer the client the opportunity to use the toilet every 15 min while in restraints.
D. Notify the provider about the use of restraints after the restraints are removed.
65. A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
A. “The client asked me to go on a date with him, but I refused.”
B. “The client generally shares his feelings during group therapy sessions.”
C. “The client needs to accept responsibility for his substance use.”
D. “The client is just like my brother who finally overcame his habit.”
66. A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall the attack. The nurse should identify that the client is using which of the following defense mechanisms?
A. Repression
B. Reaction formation
C. Suppression
D. Sublimation
67. A nurse is caring for a client who states, “I have been having trouble sleeping for the last several months,” Which of the following responses should the nurse make?
A. “You should take a 2 hour nap during the afternoon.”
B. “You should relax by watching a television show in bed before going to sleep.”
C. “You should plan to exercise 2 hours before going to sleep.”
D. “You should avoid stressful activities prior to going to sleep.”
68. A nurse in an acute care mental health facility is receiving a morning report for a group of clients. Which of the following clients should the nurse plan to assess first?
A. A client who has posttraumatic stress disorder and is reported to have experienced a flashback during the night.
B. A client who is depressed and occasionally expresses suicidal thoughts but whose mood is reported to have improved this morning.
C. A client who was recently admitted, has severe negative manifestations of schizophrenia, and is refusing to get up for breakfast.
D. A client who has generalized anxiety disorder and reports being frightened about an upcoming dental appointment.
69. A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?
A. Remove the restraint when the client calmly follows commands.
B. Document the client’s behavior hourly on a flow-sheet.
C. Observe the client’s behavior once every 15 min.
D. Request a PRN client prescription for restraints from the provider.
70. A nurse manager is observing a newly licensed nurse preparing to administer and IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
A. Demonstrate how to verbally de-escalate the situation.
B. Stop the newly licensed nurse from administering the medication.
C. Assess the need for physical restraints.
D. Discuss the purpose of the medication with the client.