Question: A nurse is providing teaching to a client who has a new prescription for phenelzine (Nardil) an MAOI. Which of the following client statements indicates understanding of the teaching?
Answer Choices: a. “I’ll take the medication at night due to its sedative qualities.” b. “This medication will help me lose the weight that I have gained over the past year.” c. “While taking this medication, I’ll need to stay out of the sun to avoid a skin rash.” d. “I will need to change my dietary habits while on this medication.”
Answer: d. “I will need to change my dietary habits while on this medication.”
Question: A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s adult daughter, which of the following statements is the highest priority to report to the provider?
Answer Choices: a. “My mother received her flu vaccine last month.” b. “My mother is currently on furosemide for her congestive heart failure.” c. “My mother has diabetes that is controlled by her diet.” d. “My mother recently completed a course of prednisone for acute bronchitis.”
Answer: b. “My mother is currently on furosemide for her congestive heart failure.”
Question: A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is therapeutic?
Answer Choices: a. “Losing someone close to you must be very upsetting.” b. “I know how difficult it is to lose a loved one.” c. “I feel very sorry for the loneliness you must be experiencing.” d. “Suicide is not an appropriate way to cope with loss.”
Answer: a. “Losing someone close to you must be very upsetting.”
Question: A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of her alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if she drinks alcohol. This form of treatment is an example of which of the following?
Answer Choices: a. Aversion therapy b. De-sensitization therapy c. Flooding d. Dialectical behavioral therapy
Answer: a. Aversion therapy
Question: In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
Answer Choices: a. The patient will identify two community resources for the treatment of substance abuse by discharge. b. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. c. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. d. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
Answer: b. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
Question: A nurse is caring for a client who lost his mother to cancer last month. Which of the following statements made by the nurse is a nontherapeutic response?
Answer Choices: a. “Tell me more about how you are feeling.” b. “I understand just how you feel. I felt the same when my mother died.” c. “Let’s discuss how you have been coping.” d. “You sound angry. Anger is a normal feeling associated with loss.”
Answer: b. “I understand just how you feel. I felt the same when my mother died.”
Question: A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
Answer Choices: a. Move in close to the client so you will not have to raise your voice. b. Walk away from the client and let him cool off. c. Request that other staff members remain close by to assist. d. Insist the client stop yelling and show appropriate behavior.
Answer: c. Request that other staff members remain close by to assist.
Question: A client tells a student nurse, “Don’t tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me.” Which of the following actions should the nurse take?
Answer Choices: a. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. b. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. c. Report the incident, but do not inform the client of the intention to do so. d. Keep the client’s communication confidential, but watch the client and his roommate closely.
Answer: a. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.
Question: A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
Answer Choices: a. Stimulate cognitive function by discussing new and challenging topics with the patient. b. Assist the patient to perform simple tasks by giving step-by-step directions. c. Promote the use of the patient’s sense of humor by telling jokes or riddles. d. Reduce frustration by performing activities of daily living for the patient.
Answer: b. Assist the patient to perform simple tasks by giving step-by-step directions.
Question: An emergency department nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child’s back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services?
Answer Choices: a. “We do not believe in immunization of our children.” b. “Our child would rather play alone than with other children.” c. “Our child is always creating problems for the family.” d. “We home-school our children in order to include religious education.”
Answer: c. “Our child is always creating problems for the family.”
Question: A patient who suffered a traumatic brain injury several years ago is now being treated for explosive behavior and impulsivity with haloperidol (Haldol). The nurse monitors the patient for which of the following that indicates the presence of an adverse effect of this medication?
Answer Choices: a. Hypotension b. Blurred vision c. Nausea d. Excessive salivation
Answer: d. Excessive salivation
Question: A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” What is the most accurate assessment of the situation? The patient:
Answer Choices: a. may have sustained a head injury before admission. b. is attempting to obtain attention by manipulating staff. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.
Answer: c. has symptoms of alcohol withdrawal delirium.
Question: A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, “I want to go to school but we can’t afford a babysitter. It doesn’t matter though; I’m too dumb to learn.” What preliminary assessment is evident?
Answer Choices: a. Child and siblings are experiencing neglect. b. Insufficient data are present to make an assessment. c. Children are being taken care of appropriately. d. Children are at a high risk for physical abuse.
Answer: a. Child and siblings are experiencing neglect.
Question: In performing a suicide lethality assessment with a suicidal client, the nurse most appropriately asks the client:
Answer Choices: a. “Do you have thoughts of self-harm?” b. “Do you have any thoughts of killing yourself?” c. “Do you wish your life was different?” d. “Do you have a death wish?”
Answer: b. “Do you have any thoughts of killing yourself?”