Question: A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?
Answer Options: Discourage the client from forming new relationships. Offer the client advice about various treatment choices. Change the subject when the client becomes upset. Allow the client unlimited time for the grieving process.
Answer: Allow the client unlimited time for the grieving process.
Question: A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?
Answer Options: Assist the client to ambulate for the first time following the procedure. Give the client atropine 30 min before the procedure. Witness the client’s signature on the consent for the procedure. Check the client’s condition after the procedure.
Answer: Check the client’s condition after the procedure.
Question: A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?
Answer Options: Set short- and long-term objectives for the future. Evaluate progress toward predetermined goals. Establish boundaries between the nurse and the client. Inform the client about confidentiality rights.
Answer: Establish boundaries between the nurse and the client.
Question: A nurse is caring for a client who has schizophrenia and is experiencing a delusion. Which of the following actions should the nurse take?
Answer Options: Contradict the client’s delusional beliefs, Allow the client to focus on the delusion for as long as they want, Reinforce the importance of controlling impulses with the client, Ask the client to describe their beliefs about the delusion.
Answer: Ask the client to describe their beliefs about the delusion.
Question: A nurse is initiating the plan of care for a client who has anorexia nervosa.
Answer Options: The nurse should first address the client’s heart rate followed by the client’s hair loss, Russell’s sign, skin turgor.
Answer: The nurse should first address the client’s heart rate followed by the client’s skin turgor.
Question: A nurse is assessing a client’s communication patterns. The client states, “My partner is always criticizing me.” This statement is an example of which of the following types of dysfunctional communication?
Answer Options: Distracting, Placating, Manipulating, Generalizing.
Answer: Generalizing.
Question: A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?
Answer Options: Monitor the client for splitting behaviors, Provide written information about the client’s treatment plan, Encourage countertransference when developing the nurse-client relationship, Isolate the client from social or group interactions.
Answer: Provide written information about the client’s treatment plan.
Question: A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?
Answer Options: Disulfiram, Bupropion, Buprenorphine, Chlordiazepoxide.
Answer: Chlordiazepoxide.
Question: A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?
Answer Options: “My spiritual advisor has increased visits since I became ill,” “I gain comfort from meditation,” “Therapy is often scheduled during my daily meditation time,” “My faith gives me hope during difficult times.”
Answer: “My spiritual advisor has increased visits since I became ill.”
Question: A nurse is planning care for a client who has borderline personality disorder. Which of the following interventions should the nurse plan to include to assist the client with impaired social interactions with others?
Answer Options: Assign the same staff members daily to provide care for the client, Encourage dependent behaviors, Avoid discussing maladaptive behaviors with the client, Explore feelings of abandonment.
Answer: Assign the same staff members daily to provide care for the client.
Question: A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?
Answer Options: A client who reports that he enjoys smoking marijuana on weekends, A client who reports lying to his provider about having suicidal ideation, A client who reports that her partner ties their child to a bed as punishment, A client who reports that she took $20 from the cash register where she works.
Answer: A client who reports that her partner ties their child to a bed as punishment.
Question: For which of the following clients should the nurse implement seizure precautions?
Answer Options: A client who is experiencing stimulant withdrawal, A client who is experiencing alcohol withdrawal, A client who is experiencing cannabis withdrawal, A client who is experiencing opioid withdrawal.
Answer: A client who is experiencing alcohol withdrawal.
Question: A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?
Answer Options: Jaundice, Decreased libido, Urinary retention, Bruising.
Answer: Decreased libido.
Question: A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?
Answer Options: “I will avoid talking about events that upset me,” “I will stay in bed on days when I feel exhausted,” “I will rely on my partner to plan out my schedule each day,” “I will use the coping mechanisms that helped me in the past.”
Answer: “I will use the coping mechanisms that helped me in the past.”
Question: A nurse is caring for an older adult client. The client has a urinary tract infection and is alert and oriented x3, with confusion about time and place in the evening.
Answer Options: The nurse should recognize the client is at risk for developing dementia, mania, delirium, as evidenced by the client’s orientation, vital signs, pain score.
Answer: The nurse should recognize the client is at risk for developing delirium as evidenced by the client’s orientation.
Question: 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?
Answer Options: The client is able to follow commands, The client refuses to take his medication unless he is released, The client states that he will harm himself unless the restraints are removed, The client demonstrates that he is oriented to person, place, and time.
Answer: The client states that he will harm himself unless the restraints are removed.
Question: A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client’s plan of care?
Answer Options: Monitor the client’s bathroom trips, Allow the client’s family to bring the client food, Encourage the client to exercise frequently, Allow the client to create their own meal schedule.
Answer: Monitor the client’s bathroom trips.
Question: A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching?
Answer Options: The client exhibits an inflated sense of self, The client begins sleeping more than usual, The client develops an inability to concentrate, The client increases participation in social activities.
Answer: The client develops an inability to concentrate.
Question: 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?
Answer Options: The bed is in the low position, Outside doors have locks, The room has an area rug, Hallways are long distances.
Answer: The room has an area rug.
Question: A nurse observes the caregiver of a client who has Alzheimer’s disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?
Answer Options: Refer the caregiver to a local support group, Offer to talk with the caregiver about their feelings, Discuss relaxation techniques with the caregiver, Consult social services to explore counseling for the caregiver.
Answer: Offer to talk with the caregiver about their feelings.
Question: A nurse is preparing for an interprofessional meeting to discuss the plan of care for a client. Which of the following information should the nurse plan to communicate to a social worker?
Answer Options: The client reports frustration with finding an activity to relieve restless energy, The client has trouble remembering prescribed food restrictions, The client will be unable to return home after discharge, The client asks to talk to someone about changes in their spiritual beliefs.
Answer: The client will be unable to return home after discharge.
Question: A nurse is admitting a client for alcohol use disorder. The client is at risk for developing alcohol withdrawal. Which findings require immediate follow-up by the nurse?
Answer Options: Impaired cognition, Insomnia, Seizures, Increased blood pressure, Increased heart rate, Diaphoresis, Lack of appetite, Vomiting, Tremulousness, Malaise.
Answer: Seizures, Increased blood pressure, Increased heart rate, Diaphoresis.
Question: A nurse is planning care for a client who is experiencing alcohol withdrawal. For each potential provider’s prescription, specify if the potential prescription is anticipated or contraindicated for the client. Anticipated: Nutritional consult, Group therapy, Perform Alcohol Use Disorders Identification Test (AUDIT), Schedule electroconvulsive therapy (ECT), Complete blood count and basic metabolic profile. Contraindicated: Methadone 40 mg PO daily, Propranolol 40 mg PO twice a day, Diazepam 10 mg PO three times a day.
Answer: (Specified as per the context given for each treatment option.)
Question: 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?
Answer Options: The client is able to follow commands, The client refuses to take his medication unless he is released, The client states that he will harm himself unless the restraints are removed, The client demonstrates that he is oriented to person, place, and time.
Answer: The client states that he will harm himself unless the restraints are removed.