A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention sh
...
A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?
A. Report the client’s serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
1. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the it.
C. Is using a loud voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
2. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stresseadboirubt..cI ojumst/wheansti to go to sleep.” The RN should plan one-on-one observation of the client based on which statement?
A. “What should I do? Nothing
B. “I have been so tired lately and needed to sleep.”
C. “I really think that I don’t need to be here.”
D. “I don’t want to walk. Nothing matters anymore.”
3. The RN is performing intake interavibeiwrbs.actoamp/shyecshiiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of
which substance places the client at highest risk for myocardial infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana
4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client?
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
5. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the morning and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client’s appetite and pattern of sleep.
B. Assess the client’s feelings about the hospital stay.
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on the client every 30 minutes.
6. A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distract her by offering her finger foods.
D. Ignore the client’s acting out behavior.
7. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
A. Unless your sister has a medaicbailrbed.cuocamti/ohne, siginore her comments.
B. I can hear that your sister's comments are overwhelming you.
C. Do you think it’s possible thatayboirubm.cigohmt /bheeasihypochondriac?
D. Besides your sister’s comments, what in your life is troubling you?
8. A mental health worker is caring faobr iarbc.liceonmt w/hitheseiscalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
A. Is attempting the physically reasbtrirabin.cthoemp/ahteiesnit.
B. Remains at a distance of 4 feet from the client.
C. Tells the client to go to the quaiebtirabre.caoomf t/hheesuni it.
D. Is using a load voice to talk to the client.
9. When developing a plan of careafobrirabc.clioenmt /ahdemsiitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has
the highest priority?
A. Impaired comfort.
B. Risk for injury.
C. Ineffective breathing pattern.
D. Ineffective coping.
10. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity.
11. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
A. Dim the lights in the room to help the patient feel calm.
B. Sit within two feet of the client to enhance level of safety and security.
C. Reduce the noise level in the room by turning off the television and radio.
D. Position table between the client and the RN for extra personal space.
12. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
A. Purchase a gun to use for protection.
B. Establish a code with family and friends to signify violence.
C. Take a self-defense course that retaliates the abuser with injury.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
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13. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a
day. Which information should the RN report to the HCP immediately?
A. Short term memory loss.
B. Five pound weight gain
C. Decreased affect.
D. Nausea and vomiting.
14. A homeless client who reports pressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement waitbhiirnbt.hceofmirs/th2e4sihours after treatment is initiated?
A. Allow the client to rest and sleep.
B. Ensure client attend groups aadbdirrebs.sciongmc/ohpeisngi
C. Begin planning for the clients discharge.
D. Encourage verbalization of feaeblinirgbs..com/hesi
skills for dealing with depression.
15. A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
A. Admit to others that he is a substance abuser.
B. Remain alcohol free for 12 hours prior to first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Completely sustain from heroin or cocaine use.
16. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
A. At least I hit the wall instead of hitting the psychiatric aide.
B. I am here because the police thought I was doing something wrong.
C. I want to be here because I know it is the best psychiatric facility.
D. Don’t believe everything my family tells you, I am not crazy.
17. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?
A. Insight and judgement.
B. Mood and affect.
C. Remote memory.
D. Level of concentration.
18. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
A. Explain that the feces belong in the toilet.
B. Show the client how to clean the walls.
C. Escort the client out of the bathroom.
D. Assist the client to clean the walls
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19. 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 experiencaebiisrbm.coostmli/kheelysrielated to taking olanzapine?
A. Weight gain of 75 lbs.
B. Thoughts of wanting to hurt himself.
C. Frequent days with diarrhea.
D. Alerted liver function test.
20. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fracturesa.bTihrbe.ccloiemnt/’shebsloiod alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit
signs and symptoms of delirium tremaebnirsb(.DcoTsm)?/hesi
A. Prochlorperazine (Compazine) 5 mg IM.
B. Hydromorphone (Dialuadid) 2abmigrbI.Mc.om/hesi
C. Chlorpromazine (Thorazine) 50 mg IM.
D. Lorazepam (Ativan) 2 mg IM.
21. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?
A. Deficient diversional activity related to excess energy level. B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity.
22. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
24. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client's appetite and pattern of sleep.
B. Assess the client's feelings aboutatbhierbh.ocsopmita/lhsetasyi .
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on thaebcilriebn.tceovmer/yhe3s0iminutes.
25. A patient who has been on an aantbidirebp.rceossma/nhtefosri 2 weeks. What should you watch for?
26. patient states "I can't get my thoaubghirtbs.tcoogmeth/heer sI ishould really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? :
27. A patient won't take oral meds thaabtiirsbg.cooinmg /thherosuigh alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it
will help with recovery?
28. A nurse visits a community half awbaiyrbh.ocuosme w/hitehsoi ne bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper
towels.
29. Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction?
30. Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit
31. male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client’s behavior. When admitting the client to the unit, which action is most important for the nurse to take?
A. Ask the client about his recent substance use
C. Determine the number of previous hospitalizations
D. Assess the client from head-to-toe
32. An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but he is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives?
A. Assess the clients self-esteem needs.
B. Determine the clients expectations for treatment. C. Discuss methods for clearly communicating.
D. Identify ways to develop support systems.
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33. Chronically depressed older male client of a long term care facility becomes more reclusive
and today refuses to leave room: May Iasibt iwrbit.hcfoomr y/ohueaswi
hile
34. . During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming upathbeirnbe.xctodmay/.hWehsait intervention is most important for the RN to implement during the admission process?
1. Assist the client in developing aaltberinrabt.icveocmop/hinegssikills.
2. Remain calm and use a matter of fact approach.
3. Ask the client why she is so anxaiobuisrb.com/hesi
4. Administer a PRN sedative to help relieve her anxiety.
35. .The nurse is assessing a client withapboisrtbpa.crtoummd/hepersesi sion for changes in the …….Sign & Symptoms that are consistent with post partum depression? Select all that apply
-distrubed sleep, sadness, poor concentraabtioirnb.
36. A client with borderline personality disorder tells the nurse, “You are the best nurse on the unit! The other nurses don’t care about ambeirthbe.cwoamy y/houedsoi .” Which response is best for the nurse to provide this client?
a.) “I am not the best nurse. All the nurses are good.”
b.) “The other nurses and I are here to help you get better” c.) “You don’t think the other nurses care about you?”
d.) “I do care about you as a person but nothing more.”
A sales executive presents to the psychiatric office for an initial evaluation, and tells the nurse “My therapist said my wife was having an affair. I had drinking problem for years, but I have been sober for 3 years. I believe in God……. What response is best for the nurse to provide?
38. The nurse is taking the history of a young adult female who is 5 feet 4 inches tall and weighs. What is the most important for the nurse to address immediately?
39. A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship: explore the client's feelings related to discharge
40. a client is being discharged with a prescription of paroxetine. which in truction is most important for the nurse to include in this client’s discharge? Avoid alcohol
41. client sitting in corner of day room during admission assessment, what nursing action -
42. An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement?
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A. Tell the client to call Adult Protective Services if his son's abuse continues.
B. Refer the client to a program for vaicbtiirmbs.coofmdo/hmeessitic violence
C. Verify the client's report by determining if there is physical evidence of abuse
D. Assist the client in developing an emergency safety plan
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43. THE NURSE IS CARING FOR A CLIENT WHO HAD A MYOCARDIAL INFARCTION AND IS EXPERIENCING DEATH ANaXbIiErbT.Yc.oWmH/hICeHsiACTION SHOULD THE NURSE
IMPLEMENT?
44. A client with schizophrenia explainas tbhiartbs.hceohmas/h20eschi ildren and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN
to provide/
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A. “Let’s go ask another RN is this is true.”
B. “My name tag shows that I am aaRbNirbh.ecreo.”m/hesi
C. “I can’t possibly be one if your children.”
D. “I know that you don’t have 20 achbilidrbre.nc.o” m/hesi
45. male client admitted depression and self mutilation -
46. male employee says i'm gonna shoot a coworker -
Assessing male client with paranoia, which behavior can this client be expected to exhibit -
A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client’s chief complaint in the medical record?
a.) Client reported that she had sexual relations against her will.
b.) Client claims that she was forced to participate in sexual intercourse. c.) Client has been sexually assaulted.
d.) Client states, “my date raped me tonight.”
41. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent
42. A female client with obsessive compulsive disorder complains that she is feels “driven” to check the locks on her front door at .. Which response is best for the nurse to provide?
a. have you had a bad experience related to unlocked doors?
b. What are your thoughts when you are checking the locks?
c. feelings of being drive to do something are related to anxiety
d. repeating the same behavior helps you to diminish your anxiety
43. The nurse on the day shift receives raebpoirrbt .acbooumt a/hceliseni t with depression who was in bed most of the weekend. The nurse .. the morning and finds the client in bed. What intervention is best for
the nurse to implement?
abirb.com/hesi
a. explain that staff will check on the client every 30 mins
b. assist the client to get out of bed and involved in an activity
c. monitor the client’s appetite andapbaitrtber.ncoofmsl/eheep si
d. assess the client’s feelings about the hospital stay
44. a client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just…” The nurse should plan one-on-one observation of the client based on which statement?
a. I really think that I don’t need toabbeirhbe.rceom/hesi
b. I don’t want to talk. Nothing matters anymore
c. I have been so tired lately and naeebdierdb.tocoslmee/phesi
d. What should I do? Nothing seems to help
45. What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weekas?birb.com/hesi
a. ventilate feelings of sadness
b. eats three meals a day
c. participates in group meetings
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d. does not attempt to commit suicide
46. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker. . intervention by the nurse?
a. remains at a distance of 4 feet from the client b. is attempting to physically restrains the client
c. tells the client to go to the quiet area of the unit
d. is using a loud voice to talk to the client
47. An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What should the nurse implement?
a. assist the client to clean the walls
b. show the client how to clean the walls c. escort the client out of the bathroom
d. explain that feces belong in the toilet
48. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is...laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister...hypochondriac. Which response is best for the nurse to provide?
a. I can hear your sister’s comments are overwhelming you
b. Do you think it is possible that you might be a hypochondriac?
c. unless your sister has a medical education, ignore her comments
d. Besides your sister’s comments, what in your life is troubling you?
49. After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take?
A. instruct the client to reduce the volume of his voice
B. administer a PRN sedative by inajebcitriobn.com/hesi
C. accompany the client to a quiet area of the unit
D. encourage the client to attend a support group
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50. A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoaybthirebt.hcinogms t/hhaet soni ce gave them pleasure. Which coping strategy should the nurse include in the plan of care?
A. Relax and reduce the amount of effort to solve the problem
B. Recall methods that were most successful in the past
C. reach out to family and friends about feelings of abandonment
D. turn to other activities to take onaeb’sirmbi.ncdoomff/ohfetshei issues
51. A male college student visits the student health center for his annual physical examination.
His vital signs and blood glucose...rangae.bHiribs .hceoigmht/ihse6sfieet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain?
A. 24-hour nutritional history
B. body mass index
C. basal metabolic rate
D. complete blood count
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52. A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family?
A. Despite his illness, the client should be able to live away from home B. his serum lithium levels should be routinely evaluated
C. he should plan to participate in group or individual therapy while at college
D. he should be aware of the symptoms of his illness
53. A client who is admitted to the substance abuse center reports having nightmares -
54. A client admitted to the psychiatric unit for alcohol dependency- .
55. During the initial nursing interview. “sometimes my thoughts go so fast” -
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