1. A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?
A. The client's potassium level is 3.2
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1. A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?
A. The client's potassium level is 3.2 mEq/L
B. The client's current BMI is 14
C. The client states that she knows she can't be perfect
D. The client reports following various cooking blogs
2. A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity?
A. WBC 6,000/mm3
B. Sodium 132 mEq/L
C. Calcium 10.0 mg/dL
D. Aspartate aminotransferase 40 units/L
3. A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
A. Stop the newly licensed nurse from administering the medication
B. Demonstrate how to verbally de-escalate the situation
C. Discuss the purpose of the medication with the client
D. Assess the need for physical restrains
4. A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me." The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
A. Cocaine
B. Alcohol
C. Opium
D. Heroin
5. A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply).
A. Bradycardia
B. Lanugo
C. Diarrhea
D. Russell's sign
E. Hypotension
6. A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?
A. Risperidone
B. Methylphenidate
C. Valproate
D. Lithium
7.
8. A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?
A. Jaundice
B. Bruising
C. Decreased libido
D. Urinary retention
9. A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?
A. The client's mother has asthma
B. The client's father lives in the client's home
C. The client is the oldest of their siblings
D. The client has several siblings
10. A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?
A. The client says he feels guilty about not spending more time with his partner
B. The client states that he is unable to eat more than once a day
C. The client frequently recalls negative experiences that occurred during his marriage
D. The client relates that he is angry that the provider did not save his partner's life
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37. A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has a major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?
A. Significant weight loss
B. Psychomotor retardation
C. Markedly neglected hygiene
D. Poor problem - solving skills
38. A nurse is providing counselling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify in the role of monopolizer?
A. The adolescent son who refuses to share personal feelings.
B. The adolescent daughter who attempts to dominate the discussion
C. The father who intervenes whenever the siblings argue.
D. The mother who expresses hostility toward the spouse.
39. A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?
A. "Let's discuss what you feel embarrassed about."
B. "Lots of people feel ashamed to tell their secrets."
C. "You shouldn't feel embarrassed to talk to me."
D. "You will feel better if you tell me what you did last night."
40. A nurse is performing an admission assessment for a client who was transferred from another mental health facility. The nurse suspects negligence. Which of the following actions should the nurse take?
A. Write a detailed accusation against the previous facility
B. Notify the American Nurses Association of the occurrence.
C. Document a factual account of the findings in the client's medical record
D. Complete an incident report and include it in the client's medical record.
41. A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
A. "I don't know how I could cope if I didn't have my family's support."
B. "I don't feel anything but numbness anymore."
C. "it'll be a long time before I'm happy again."
D. "I feel like I'm angry at the whole world right now."
42. A nurse is assessing a client who has bipolar disorder and is taking lamotrigine. Which of the following findings is the nurse's priority to report?
A. ALT 20 units/L
B. Platelets 200, 000/ mm3
C. Photosensitivity
D. Skin rash
43. A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?
A. Demonstrate a sympathetic attitude toward the client when providing care.
B. Encourage the use of countertransference for the client.
C. Provide consistent boundaries for the client
D. Maintain consistency in assigning health care staff for the client.
44. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates an accurate understanding of this medication's effects?
A. "I'll take my medicine at bedtime because it will make me drowsy."
B. "This medicine will help me relax and feel less anxious."
C. "I know that I will be able to think more clearly now."
D. "I need to tell my doctor if I start gaining weight."
45. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?
A. Veracity
B. Justice
C. Beneficence
D. Autonomy
46. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?
A. Offer the client the medication at the next scheduled dose time.
B. Implement consequences until the client takes the medication.
C. Inform the client that he does not have the right to refuse the medication.
D. Administrate the medication to the client via IM injection.
47. A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the client's condition. Which of the following is the appropriate nursing action?
A. Consult the client
B. Consult the client's family
C. Contact the facility legal department
D. Contact the provider
48. A nurse is assessing a client who has schizophrenia. which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply)
A. Auditory hallucinations
B. Flight of ideas
C. Decreased motivation
D. Impaired memory
E. Delusions of grandeur
49. a nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?
A. "Are you having thoughts about harming yourself?"
B. "Who do you talk to when you need help?"
C. "How do you think this event is affecting your life right now?"
D. "What do you usually do to cope with problems in your life?"
50. a nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment. Which of the following actions should the nurse plan to take next?
A. Request a mental health consultation for the client
B. Provide a trained advocate to stay with the client
C. Offer prophylactic medication to prevent STIs.
D. Conduct a pregnancy test.
51. A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
A. Ask the client to sign a no- suicide contract.
B. Establish a rapport to foster trust
C. Encourage the client to participate in group therapy
D. Implement continuous one to one observation.
52. A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?
A. A client who has schizophrenia personality disorder
B. A client who has moderate- stage Alzheimer's disease
C. A client who has a history of dependent personality disorder
D. A client who has a history of alcohol disorder.
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