Question: Which of the following data indicates early signs of withdrawal?
Answer Choices: Not provided.
Answer: a. Diaphoresis, vomiting, and headache
Question: The nurse is caring for a client who has tardive dyskinesia. Which of the following assessment tools is appropriate?
Answer Choices: a. Abnormal Involuntary Movement Scale (AIMS) b. CAGE Assessment c. Hamilton Rating Scale for Anxiety d. SAD PERSONS Scale
Answer: a. Abnormal Involuntary Movement Scale (AIMS)
Question: The child with autism spectrum disorder (ASD) has difficulty with trust. With this in mind, which of the following nursing actions would be most appropriate?
Answer Choices: a. Let child know in advance if there is a change in his caregiver’s schedule. b. Allow for flexibility in the daily schedule. c. Assign different staff member each day so the child learns that everyone can be trusted. d. Encourage the staff to hold the child as often as possible, conveying trust through touch.
Answer: a. Let child know in advance if there is a change in his caregiver’s schedule.
Question: An 18-year-old woman is admitted to a mental health unit with the diagnosis of anorexia nervosa. The nurse plans care, knowing that health promotion should focus on:
Answer Choices: a. Providing a supportive environment b. Helping the client identify and examine dysfunctional thoughts and beliefs c. Emphasizing social interaction with clients who are withdrawn d. Examining intrapsychic conflicts and past issues
Answer: b. Helping the client identify and examine dysfunctional thoughts and beliefs
Question: A patient diagnosed with paranoid schizophrenia says “My co-workers are out to get me. I also saw two doctors plotting to kill me.” What positive symptom is the patient experiencing?
Answer Choices: a. Thought insertion b. Ideas of reference c. Illusion d. Delusions of grandeur
Answer: b. Ideas of reference
Question: A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicate the client is experiencing depersonalization?
Answer Choices: a. “I am a superhero and am immortal.” b. “I know that you are stealing my thoughts.” c. “I feel monsters pinching me all over.” d. “I am no one, and everyone is me.”
Answer: d. “I am no one, and everyone is me.”
Question: A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to “kill your doctor.” Which of the following is the priority action for the nurse to take?
Answer Choices: a. Use therapeutic communication to discuss the hallucination with the client. b. Initiate one-on-one observation of the client. c. Focus the client on reality. d. Notify the provider of the client’s statement.
Answer: d. Notify the provider of the client’s statement.
Question: A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following is an expected finding?
Answer Choices: a. Demonstrates extreme anxiety when placed in a social situation. b. Becomes agitated if his personal area is not neat and orderly. c. Has difficulty making even simple decisions. d. Attempts to get special favors from the staff.
Answer: d. Attempts to get special favors from the staff.
Question: A nurse is caring for a client who has narcissistic personality disorder. Which of the following statements is not typical of a client who has this type of personality disorder?
Answer Choices: a. “I’m going to be very successful.” b. “People always recognize my authority.” c. “I enjoy looking at myself in the mirror.” d. “I am no better or worse than most people.”
Answer: d. “I am no better or worse than most people.”
Question: A nurse in a long-term care facility is caring for a resident who has major neurocognitive disorder and attempts to wander out of the building. The client states, “I have to get home.” Which of the following is an appropriate response by the nurse?
Answer Choices: a. “You cannot go outside without a staff member.” b. “I am your nurse. Let’s walk together to your room.” c. “You have forgotten that this is your home.” d. “Why would you want to leave? Aren’t you happy with your care?”
Answer: b. “I am your nurse. Let’s walk together to your room.”
Question: A nurse is caring for a client who has Alzheimer’s disease and is beginning to experience noticeable short-term memory loss. When discussing a new prescription for donepezil (Aricept), the nurse should include which of the following teaching?
Answer Choices: a. “You should avoid taking over-the-counter acetaminophen while on donepezil.” b. “You can expect the progression of cognitive decline to slow, but not stop with donepezil.” c. “You will be screened for underlying kidney disease prior to starting donepezil.” d. “You should stop taking donepezil if you experience nausea or diarrhea.”
Answer: b. “You can expect the progression of cognitive decline to slow, but not stop with donepezil.”
Question: A nurse is discussing routine follow-up needs for a client who was started on clozapine (Clozaril), an atypical, while hospitalized. The nurse should inform the client of the need for routine monitoring of which of the following, especially if the client notices a sore throat and fever?
Answer Choices: a. WBCs, ANC and platelet counts b. ALT and AST c. Serum sodium and potassium d. BUN and Creatinine
Answer: a. WBCs, ANC and platelet counts
Question: A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications?
Answer Choices: a. First Generation: Chlorpromazine (Thorazine) b. SNRI: Pristiq c. Second Generation: Olanzapine (Zyprexa) d. SSRI: Prozac
Answer: c. Second Generation: Olanzapine (Zyprexa)
Question: A young adult has heavily abused alcohol and prescription drugs since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the nurse presents reality while demonstrating compassion?
Answer Choices: a. “Addiction is powerful. You are young yet cannot walk without a cane. If you don’t make changes, your health will continue to suffer.” b. “It’s time to face your addiction. You are disappointing your family and must stop drinking for the sake of the people who love you.” c. “I know you must feel self-conscious about using a cane at your age, but it will help prevent falls.” d. “Addiction is a fatal disease. If you continue to drink like you have done in the past, you will not live another 10 years.”
Answer: c. “I know you must feel self-conscious about using a cane at your age, but it will help prevent falls.”
Question: A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client’s plan of care?
Answer Choices: a. Implement one-to-one observation during and 30 minutes after meal times. b. Establish consequences for purging behavior. c. Provide the client with a high-fat diet at the start of treatment. d. Allow the client to select preferred meal times.
Answer: a. Implement one-to-one observation during and 30 minutes after meal times.