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 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 client’s history should the nurse report to the provider?
Answer Options: Knee arthroplasty 1 month ago Hypothyroidism Hepatitis B infection Recent head injury
Answer: Recent head injury
Question: A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?
Answer Options: Bowel sounds Oxygen saturation Pupil response Blood pressure
Answer: Blood pressure
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: Ask the client to describe their beliefs about the delusion. Reinforce the importance of controlling impulses with the client. Contradict the client’s delusional beliefs. Allow the client to focus on the delusion for as long as they want.
Answer: Ask the client to describe their beliefs about the delusion.
Question: A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?
Answer Options: Reports eating twice in the past week States that he hasn’t bathed in 2 days Speaks in rhyming sentences Makes inappropriate sexual comments
Answer: Speaks in rhyming sentences
Question: A nurse is caring for a client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Answer Options: Offer hydration and nutrition to the client every 2 hr. Have a staff member check on the client every 30 min. Ask the provider to renew the prescription every 8 hr. Assess the client’s need for toileting every 15 min.
Answer: Have a staff member check on the client every 30 min.
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 providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Answer Options: Put locks at the top of doors. Install sensor devices on outside doors. Place the client in a reclining chair. Encourage physical activity prior to bed time. Position the mattress on the floor.
Answer: Put locks at the top of doors, Install sensor devices on outside doors.
Question: A nurse is assessing a client during a follow-up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?
Answer Options: Tell the client they will be admitted to an inpatient care facility if they do not take the medication. Ask the client if the medication is causing adverse effects. Discuss the provider’s goals for the client’s care. Request the provider prescribe a second antipsychotic medication to the client.
Answer: Ask the client if the medication is causing adverse effects.
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 Urinary retention Decreased libido Bruising
Answer: Decreased libido
Question: A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
Answer Options: Tell the client he cannot refuse the treatment because he was involuntarily committed. Inform the client that ECT does not require client consent. Ask the client’s family to encourage the client to receive ECT. Document the client’s refusal of the treatment in the medical record.
Answer: Document the client’s refusal of the treatment in the medical record.
Question: 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 first 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?
Answer Options: Sublimation Compensation Suppression Regression
Answer: Suppression
Question: A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
Answer Options: Encourage the client to have the procedure. Obtain consent from the client’s family member. Request another nurse to review the procedure with the client. Inform the client that they have the legal right to refuse treatment at any time.
Answer: Inform the client that they have the legal right to refuse treatment at any time.
Question: A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?
Answer Options: A client who has anorexia nervosa and expresses a fear of gaining weight A client who has Alzheimer’s disease and is having difficulty remembering names of family members A client who has bipolar disorder and is exhibiting poor impulse control A client who has schizophrenia and is exhibiting clang associations in their speech
Answer: A client who has bipolar disorder and is exhibiting poor impulse control
Question: A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?
Answer Options: Writes a detailed daily activity schedule Refuses to engage in conversation Isolates self from others Reports a lack of sleep
Answer: Reports a lack of sleep
Question: A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Answer Options: Offer hydration and nutrition to the client every 2 hr. Have a staff member check on the client every 30 min. Ask the provider to renew the prescription every 8 hr. Assess the client’s need for toileting every 15 min.
Answer: Have a staff member check on the client every 30 min.