Practice Test Assessment Performance | Answered with complete solutions

Practice Test Assessment Performance | Answered with complete solutions Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of th ...

Practice Test Assessment Performance | Answered with complete solutions Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? Allow the group to handle the problem. Rationale: The phase the group process is in--initial, working, or termination--this will help determine communication styles between the group members. After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to address the situation. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? The nurse should report any case of suspected child abuse to the nurse in charge. Rationale It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? Others have had similar thoughts when under stress. Rationale The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated. The nurse is planning the care for an adult client with acute depression. Which intervention should the nurse implement to help the client deal with depression? Assist the client in exploring feelings of shame, anger, and guilt. Rationale Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings with the client is an important nursing intervention for a client who is acutely depressed. The other interventions are not indicated. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? Notify the healthcare provider of the symptoms prior to the next administration of the drug. Rationale Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? Calmly address the client's inappropriate behavior. Rationale Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? What are some ways that you can cope with your anxiety? Rationale An open-ended question that assists the client in problem-solving ways to cope with the anxiety engages the client in self management. The other responses do not allow the client to explore ways to cope with anxiety. The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) - Permit rest periods as needed. - Speaking slowly and simply. - Observe and encourage food and fluid intake. - Place the client on suicide precautions. Rationale Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state. An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide? Let's go back to the activity room and see what is going on in there. Rationale It is common for those with Alzheimer's disease (AD) to use the wrong words. Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful because clients with AD experience short-term memory loss. The other responses dismiss the client's attempt to find order, do not help her relate to the surroundings, and are frustrating which increase anxiety level. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? Accompany the client outside for an increasing amount of time each day. Rationale The process of gradual desensitization by controlled exposure to the situation which is feared, is the treatment of choice in phobic reactions. The other options are not indicated in the initial phase of desensitization. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? Assess the content of the hallucinations by asking the client what he is hearing. Rationale Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill himself or the nurse. The other actions are not indicated. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? Suggest actions to control impulsive responses toward self and others. Rationale: Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior so that he can avert the social consequences related to such behaviors. The other goals do not address the acute issue of impulse control, which is necessary to minimize the likelihood of self harm and harm to others. The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? It is a chemical imbalance in the brain that causes disorganized thinking. An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? Immediately transfer the client to intensive care unit. An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting? Agoraphobia A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to which client assessment finding? erroneous interpretation of reality. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." Which assessment findi ng should the nurse reference when initiating a referral? Moderate levels of anxiety. A young adult male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? He is unresponsive to instructions and is unable to cooperate with emetic therapy. Based on noncompliance with the medication regimen, an adult client with a diagnosis of substance abuse and schizophrenia recently had a change in prescriptions from oral fluphenazine HCl (Prolixin) to fluphenazine decanoate (Prolixin IM). What is most important to teach the client and family about this change in medication regimen? The effects of alcohol and drug interaction. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? Roast beef, baked potato with butter, and iced tea. An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? Tell the client that the nurse is there and will help her. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? Reassess client's mental status for thought processes and content. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? How can I help? A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? Stagnation. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological management for withdrawal? Excessive CNS stimulation will be reduced. An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? Encourage the client to actively participate in assigned activities on the unit. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? Let me call and leave a message for your healthcare provider. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? Schizophrenia. On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate? Participate in a group quilting project. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. Which defense mechanism is the client using? Identification A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? Allow time for the ritualistic behavior, then redirect the client to other activities.