1. A client is Prescribed Risperidone (Risperdal) for schizophrenia. Which Side Effects
Should the nurse report to the Health Provider?
Fever, Tachycardia, Diopheris (sweathing)
2. A homeless women who is well-educat
...
1. A client is Prescribed Risperidone (Risperdal) for schizophrenia. Which Side Effects
Should the nurse report to the Health Provider?
Fever, Tachycardia, Diopheris (sweathing)
2. A homeless women who is well-educated and has chronic schizophrenia is admitted to
the mental health unit when found by the police walking in the middle of the street. The
client presents with strong body odor, dirty clothes and avoliation. After a week of
neurolepticdrug therapy drug therapy, the client discusses with the nurse her thoughts
about bathing. Which statement suggest that the client is progressing?
I feel good when I take care of myself.
3. A young adult with eroded tooth enamel presents to the clinic with multiple complaints
including severe pain in the chest and upper abdomen that occurred when the client
induced vomiting after eating a large breakfast. The client also reports severe
hearthburn in the last week and describes a history of taking laxatives and eating prunes
whenever overeating. What client problem should address first?
Erosion of tooth enamel
4. A young adult male receives a prescription for disulfiram to help maintain abstinence
from alcohol. What information should the nurse include in a teaching plan for this
client?
Check labels of OTC drug for alcohol content
5. A older male resident of a long-term care facility who is chronically depressed. Has
become more reclusive and refuses to leave his room today. His family moved away from
a local area and they are unable to visit as much as they did in the past. Which comment
by the nurse is likely to be most helpful to this client?
May I sit with you for a while
6. The nurse develops a plan of care for a female client who scratches her wrist in attempt
to deal with anxiety. Which client outcome is most important to include in the plan of
care.
Demonstrates effective ways to cope with anxiety.
7. A client who recently experienced the death of a significant other arrives at the mental
health center. The client reports loss of interest in usual activities, expresses a wish to be
with the decreased significant other, has been eating very little, and has not slept in
several days. Which client statement is most important for the RN to explore at this time?
Not sleeping for several days.
8. An adolescent male client is hospitalized after he threatened a teacher in school. He
admits feeling angry because his mother tricked him and brought him tp the hospital .
The client steates that when his mother visits, he plans to her his belonging from her,
but is not going to talk to her. Which activity is most important for the nurse to complete
before the mother arrives?
Discuss methods for clearly communicating
9. The charge nurse of the psychiatric unit observes clients in the day area. Which client is
exhibiting symptoms of a conversion disorder?
A young women who suddenly goes blind with no indication of organic pathology
10. A client diagnosed with schizophrenia looks frightened and tells the nurse. “ I keep
hearing the voices telling me to hurt somebody. Don’t you hear them? Which response
is the best for the nurse to provide?
I don’t hear the voices, but you seem very frightened
11. During admissions assessment to the mental health unit, a client reports that the people
at the office, where the client works, are antagonistic and the client is thinking of the
shooting the supervisor. The client asks the nurse not to revel this to anyone else. The
nurse immediately notifies the clients therapist and other team members of the client’s
thoughts. The therapist then calls the client’s supervisors and shares the client’s
thoughts about shooting the supervisors. what outcome is appropriate based on the
action of the nurses?
The nurse is reprimanded for divulging confidential patient information without
obtaining informed consent
12. When implementing a therapeutic on a psychiatric unit, which intervention is most
important for the nurse to implement.
Encourage client participation in planning weekly activities
13. The RNurse on the evening shift receives report that a client is scheduled for
electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn
implement the evening before the scheduled ECT?
Keep The client NPO after midnight
14. A male adult comes to the mental health clinic and walks back and forth in front of the
office door, but does not enter the office. He then walks around a chair that is in the
hallway several times before sitting down in the chair. What action should the nurse take
first
Observe the client in the Chair
15. A female client is brought to the emergency department after police officers found her
disoriented, disorganized, and confused. The RN also determines that the client is
homeless and is exhibiting suspiciousness. The client’s plan of care should include what
priority problem?
Acute confusion
16. When assessing a 7-year-old girl, the nurse notes that she has multiple bruises
on her back and upper arms. The child's aunt tells the nurse that the child's
parents abuse drugs and alcohol. What intervention is most essential for the
nurse to implement? Assement
findings should be reported to the proper legal authorities
17. A male client with a long history of alcohol dependency arrives in the Emergency
Department describing the feeling of bugs crawling on his body. His blood
pressure is 170/102 , pulse rate is 110 beats/minute, and blood alcohol level
(BAL) is 0mg / (dL) . Which prescription should the nurse administer?
Lorazepam (Ativan)
18. A client on the mental health unit is becoming more agitated, shouting at the stali,
and pacing in the hallway. When a PRN medication is offered, the client refuses
the medication and defiantly sits on the floor in the middle of the unit hallway.
What nursing intervention should the nurse implement first?
Take other client in the area to the client lounge
19. A middle-aged remale client with no previous psychiatric history is seen in the mental
health clinic because her family describes her as having paranoid thoughts. On
assessment, she tells the nurse “I want to find out why these people are stalking me”
which response should the nurse provide?
It sounds like this experience id frightening you.
20. Following involvement in a MVC, a middle aged adult client is admitted to the hospital
with multiple facial fractures. The client’s blood alcohol level is high on admission.
Which PRN prescription should be administered if the client begins to exhibit signs and
symptoms of delirium tremens (DTs)?
Lorazepam (Ativan) 2mg IM.
21. A client with borderline personality disorder tells the nurse, "You are the best
nurse on the unit! The other nurses don't care about me the way you do." Which
response is best for the nurse to provide this client?
I am not the best nurse. All the nurses are good.
22. A young adult male who was recently diagnosed with bipolar disorder takes lithium
carbonate daily. He is graduating from high school next month, and he tells the school
nurse that wants to live away from home for college. What info is most important for the
nurse to provide the client and his family?
His serum lithium levels should be routinely evaluated.
23. . A male client tells the RN that he does not want to take the atypical antipsychotic drug,
olanzapine (Zypexa), because of the side effects he experienced when he took the drug for
a year. Which experience is most likely related to taking olanzapine?
Weight gain of 75 pounds
24. A client is discussing feeling related to recent loss with the nurse. The nurse remains
silent when the client says, “ I don’t know how I will gone” wha is the most likely reason
for the nurse’s behavior?
Silence allows the client to reflect on what is said
25. A successful businessman presents to the community mental health center caining of
sleeplessness and axiety over his financial status. What action should the nurse take to
assist this client in diminishing his anxiety?
Teach him to limit sugar and caffeine intake.
26. The nurse notes that a client with a history of self-mutilation has increased body tension
and is pacing in the hallway. Which nursing intervention is most important at this time
Complete a thorough room search to ensure client does not have access to objects that
can be used self-harm.
27. The nurse is planning client teaching for a 35-year-old client with early alcoholic
cirrhosis. Which self-care measures should the nurse emphasize for the client’s recovery
Vitamin b and multivitamin
28. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day.
Which information should the RN report to the HCP immediatel
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