1. When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first
a. Introd
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1. When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientation phase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past (working phase)
2. A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor (indication toxicity )
3. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority?
a. Encourage expression of feelings (acknowledge them)
b. Promote attendance at an assertiveness training group (how to be assertive rather than aggressive)
c. Assist the client to perform relaxation breathing (assist the child to calm down)
d. Use a therapeutic holding technique (the greatest risk to this child and others is harm? Therefore, the nurse’s priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury)
4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first?
a. Teach the client a relaxation technique (after the attack has subsided to prevent further escalations of anxiety)
b. Establish an exercise routine for the client (after the attack has subsided to prevent further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the following assessment findings indicates that the client is experiencing extrapyramidal adverse effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascular side effect)
d. Lip smacking and tongue rolling (indicate long-term extrapyramidal side effects associated with typical antipsychotic medications)
6. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/ml. How many mL should the nurse administer? (round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
1.5 mL
7. A nurse is assessing a client in the emergency department. The client appears agitated, his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils and agitation)
c. Benzodiazepines (decreased blood pressure)
d. Inhalants (central nervous system depression)
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