Reference no: EM133314669

Questions

1. A nurse is planning care for a client who has an adjustment disorder following a traumatic below- the-knee amputation. Which of the following actions should the nurse include?

a. Discourage the client from talking about activities he did during the amputation.

b. Respect the client's need for social isolation.

c. Encourage the client's family members to perform the client's ADLs.

d. Determine the client's stage of grief.

2. A nurse is caring for a client who has a prescription for phenelzine. The nurse should instruct the client to avoid which of the following over-the-counter medications?

a. Docusate sodium b. Ibuprofen

c. Pseudoephedrine d. Ranitidine

3. A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?

a. The client expresses feelings of guilt

b. The client relocates from a house to an apartment

c. The client is unable to perform basic hygienic tasks

d. The client gives away some of the partner's belongings

4. A nurse is assessing a client who has a paranoid personality disorder. Which of the following should the nurse expect?

a. Shows exaggerated expression of emotions

b. Believes that others are deceiving her

c. Demonstrates detachment from others

d. Takes advantage of others for her own benefit.

5. A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

a. The room has an area rug

b. Hallways are long distances

c. Outside doors have locks

d. The bed is in the low position

6. A nurse is caring for a client h has a major depressive disorder and states he has given away his personal belongings. Which of the following response should the nurse make?

a. Everyone feels a little down sometimes

b. "You should find a support group to attend."

c. "Why did you feel like giving away your belongings?"

d. "Can you tell me how you have been feeling lately?"

7. A nurse is caring for a group of clients in a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

a. A client who reports that he enjoys smoking marijuana on weekends

b. A client who reports lying to his provider about having suicidal ideation

c. A client who reports that her partner lies their child to a bed as punishment

d. A client who reports that she took $20 from the cash register where she works

8. A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

a. The client states that he will harm himself unless his restraints are removed

b. The client demonstrates that he is oriented to person, place, and

c. The client refuses to take the medication unless he is released

d. The client can follow commands

9. A nurse caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?

a. Seat the client at a dining table with six or more residents

b. Use symbols to assist the client in locating rooms

c. Provide the client with several choices for meal selection

d. Give complete directions before starting client care

10. A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicates the nurse is practicing the ethical principle of non-maleficence?

a. Being truthful with the client about the manifestation of withdrawal

b. Providing the client with quality care regardless of ability to pay for treatment

c. Withholding a prescribed medication that is causing adverse effects for the client

d. Educating the client about legal rights concerning treatment

11. A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

a. Long-term isolation

b. Schizoid personality disorder

c. Dysthymic disorder

d. Alcohol intoxication

12. A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

a. Initiates social interactions with caregivers

b. Meets own needs without manipulating others

c. Acknowledges that his delusions are not real

d. Changes behavior as a result of peer pressure.

13. A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse's neighbor. The nurse should identify that which of the following must occur when establishing a therapeutic nurse-client relationship.

a. The client regards the nurse as a friend

b. The client sees the nurse as an authority figure

c. The nurse maintains confidentiality unless the client's safety is compromised

d. The nurse seeks to spend extra time specifically with the client each day

14. A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

a. Offer snacks when the client is hungry

b. Plan a meal with the client

c. Weight the client every other day

d. Remain with the client for 1 hr. after meals

15. A nurse in a mental health facility is making a plan for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?

a. Recreational therapist

b. Clinical nurse specialist

c. Social worker

d. Occupational therapist

16. A nurse is preparing to meet with a client who was recently admitted to an outpatient mental health facility. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship?

a. Discuss the clients' responsibilities for the relationship

b. Inform the client about confidentiality issues

c. Identify the goals that the client achieved during the relationship d. Assist the client to make changes in her behavior

17. A nurse on a mental health unit placed a client in mechanical restaurants after the client assaulted another client. Which of the following actions should the nurse take?

a. Obtain a prescription for restraints on an as-needed basis

b. Evaluate the client hourly while the rest applied

c. Have the provider access the client within 1 hr. after applying the restraints.

d. Request that the provider renews the prescription for restraint every 8 hr.

18. A nurse is reviewing the medical record of a young adult client who has a new diagnosis of borderline personality disorder. Which of the following findings should the nurse identify as risk factors for this disorder? (Select all that apply)

a. The client's mother abandoned him as a child

b. The client follows a strict routine of daily activities

c. The client's father has an impulse control disorder

d. The client is a twin

e. The client reports having a substance use disorder

19. A nurse is caring for a client who has posttraumatic stress disorder. Which of the following clinical findings is associated with this disorder?

a. Depersonalization

b. Hypervigilance

c. Pressured Speech

d. Compulsive behavior

20. A nurse in an emergency department is caring for a client following a domestic dispute. The client states, "Nothing seems to go right for me and probably never will," Which of the following statements should the nurse make>

a. " You should remove yourself from this situation now"

b. "We will help you get through this. You'll be fine"

c. "What have you done to change your situation"

d. "Are you thinking about harming yourself"

21. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?

a. Provide detailed explanations to the client

b. Encourage the client to join group activities

c. Administer methylphenidate to the client

d. Dim the lights in the client's room

22. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms?

a. Recreation formation

b. Suppression

c. Identification

d. Compensation

23. A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?

a. Caution the client against feeling angry at the sibling

b. Recommend that the client participate in more solitary activities

c. Explain to the client that the duration of grief is highly variable and can last for years

d. Encourage the client to avoid discussing the events surrounding the sibling death

24. A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the clients' insights?

a. "Do you feel you need treatment?"

b. "How do you get money for your needs?"

c. "Who is the governor of this state?"

d. "What do you get when you subtract 7 from 100?"

25. A nurse is admitting a client who has alcohol use disorder. Which of the following actions the nurse should take first?

a. Determine the client's degree of physical dependence

b. Discuss the treatment plant with the client

c. Initiate a referral for treatment for alcohol use disorder

d. Document the clients alcohol use in the medical record

26. A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PSTD). Which of the following statements should the nurse include in the teaching?

a. "Talking about the traumatic experience is recommended"

b. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD"

c. "Response prevention is an effective treatment for PTSD"

d. "You should try to limit the number of hours that you sleep each day"

27. A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

a. Initiate facility procedures for emergency commitment

b. Request a prescription for varenicline from the client's provider

c. Assess the client using the CAGE questionnaire

d. Inform the client about polices for dispensing methadone

i. Exhibit 1: The client states, " I want to get better, but I don't want to go through withdrawal." No history of tobacco use. The client denies thoughts of self-injury.

28. A nurse is planning overall strategies to address problems for a client who has a borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate into the plan of care?

a. Implement measures to prevent intentional self-inflicted injury

b. Encourage the client to attend weekly support group meetings

c. Assist the client to maintain awareness of her thoughts and feelings

d. Discuss the appropriate use of assertive behavior with the client.

29. A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

a. "I will practice replacing negative thoughts with positive self-statements"

b. "I will learn how to voluntarily control my blood pressure and heart rate"

c. "I will focus on a mental image while concentrating on my breathing"

d. I will progressively relax each of my muscle groups when feeling stressed"

30. A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions does the nurse take?

a. Ask the charge nurse to obtain informed consent

b. Contact the facility social worker to obtain the consent

c. Request that the client's guardian sign the consent

d. Explain implied consent to the client's family

31. A nurse is planning to lead a support group for a client who has an alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?

a. A family member of the client

b. A unit secretary who speaks the same language as the client

c. Another client who speaks the same language as the client

d. A translator of the same gender as the client

32. A nurse in a community health facility is interviewing a client who recently lost his job. The client states, "I was fired because my boss deployed me." Which of the following defense mechanism is the client displaying?

a. Rationalization b. Repression

c. Dissociation

d. Displacement

33. A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?

a. Regression

b. Sublimation

c. Suppression d. Compensation

34. A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use?

a. Systemic desensitization to extinguish the behavior

b. Crisis intervention to decrease anxiety

c. Positive reinforcement to increase desired behavior

d. Aversion therapy to provide distraction

35. A nurse is caring for a client who is scheduled for electroconvulsive therapy(ECT). The nurse should administer which of the following medications to the client 30 min prior to decrease secretion and counteract vagal stimulation?

a. Propofol

b. Atropine sulfate

c. Dopamine

d. Succinylcholine Chloride

36. A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?

a. Insomnia

b. Sundowning

c. Rapid mood swing

d. Rambling speech

37. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the clients
history should the nurse report to the provider?

a. Knee arthroplasty 1 month ago

b. Hypothyroidism

c. Hepatitis B infection

d. Recent head injury