A nurse is collecting data from a client who has paranoid personality disorder

14. A nurse in a mental health facility is collecting data from a client who has schizophrenia.

The nurse should identify that which of the following findings is referred to as a negative

symptom of schizophrenia?

Apathy

15. A nurse is contributing to the plan of care for a client who has obsessive compulsive

disorder and continually washes her hands. Which of the following interventions should

the nurse include?

Schedule times for the client to wash her hands during the day

16. a nurse is caring for a client who gave birth to a still born fetus one week ago. "I'm so

angry my doctor didn't take better care of me and my baby.”

It is important to share what you are feeling, even if it is anger.

17. a nurse if reinforcing teaching for a client who has ADHD

Initiate a point system

18. A nurse is speaking with a client who is expressing an intense disapproval for the current

social worker. The client states, "now, where is my favorite social worker.". the nurse

should identify the client is using which of the following defense mechanism?

Reaction formation

19. A nurse is reinforcing discharge teaching with a client who has a new prescription of

alprazolam. Which of the following instructions is priority for the nurse to include?

Do not drive until your reaction to the meds is determined

20. A nurse is organizing care for a group of client. According to maslows hierchy of needs,

which of the following interventions should the nurse plan to perform first.

Offer finger foods to a client who is in the maniv phase

21. A nurse caring for an adult who has visible injuries as a result of intimate partner

violence. Which of the following actions should the nurse take?

Encourage the client to develop a safety plan

22. A nurse if developing countertransference toward a client during the working phase of

the nurse-client relationship. To correct the situation, which of the following actions

should the nurse take?

Identify personal response to the client

23. A nurse is caring for a client who has bipolar disorder and experiencing manic episode.

Which of the following intervention should the nurse take first?

Remove harmful objects from the client's room

25. A nurse on an inpatient unit is assisting with a group therapy session. During the session,

a client begins to shout, using aggressive language. Which of the following statements

should the nurse make to the client?

When you raise your voice it makes me uncomfortable and safe

26. A nurse is reinforcing teaching with the family of a client who has histrionic personality

disorder. Which of the following should the nurse instruct the family to observe for in the

client?

1. A nurse is collecting data from a client who home was recently destroyed by a fire. Which of the following findings should the nurse reports to the charge nurse?

• The client has not slept in 3 days.
• The client ate 10% of his breakfast.
• The client voices anger towards loved ones.
• The client reports episodes of nausea.

1. A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

• A client who is hearing command hallucinations
• A client who is using neologisms
• A client who is demonstrating clang associations.
• A client who is verbalizing ideas of the reference.

1. A nurse is caring for a client who has dependent personality disorder. Which of the following findings should the nurse expect?

• Avoids involvement in interpersonal relationship.
• Denise the need for therapy.
• Has difficulty expressing disagreement with others.
• Exhibits extreme anxiety in social situations.

1. A nurse contributing to the plan of care for an older adult client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following actions should the nurse recommend?

• Initiate NPO status 4 hr. prior to treatment with ECT.
• Ensure the client removes his dentures prior to ECT.
• Postpone ECT if the client reports thoughts of suicide.
• Withhold antihypertensive medication for 24 hr prior to ECT.

1. A nurse is reinforcing teaching with a client who will have electroconvulsive therapy the following day. Which of the following statement should the nurse identify as an indication that the client understands the information?

• "I could develop epilepsy after the procedure.
• "I will need to have a series of four treatments.
• "I will be awake during the procedure.

1. A nurse is collecting data from client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

• Submissive personality.
• Absence of impulsive behaviors.
• Low tolerance for frustration.
• Involved in community activities.

1. A nurse in a long-term facility is caring for an older adult client who has Alzheimer's disease. The client states that they want to go home and visit their parent, who is deceased. Which of the following techniques is an example of the nurse using validation therapy?

• Acknowledge the client's feeling.
• Reorient the client to the current time and place.
• Talk to the client about the latest news as a distraction.
• Tell the client that their parent is deceased.

1. A nurse is reinforcing teaching with a newly licensed nurse about the patient self-determination act (PSDA). Which of the following statement by the newly licensed nurse indicates an understanding of the teaching?

• "Advance directive do not apply to clients receiving mental health care.
• "A client can verbally designate a durable power of attorney.
• "The PSDA becomes applicable when a client reaches 65 years of age.
• "A witness is legally required to sign a client's living will.

1. A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply)

• Alcohol use disorder
• Sibling history of suicide
• Terminal liver cancer
• Currently married
• Access to guns in the home.

1. A nurse is visiting the home of a client who has alcohol use disorder. The client smells heavily of alcohol and his cloths are unclean. Which of the following responses should the nurse make?

• "Why aren't you taking better care of yourself?'
• "You should stop drinking and seek treatment."
• "You seem to be having a difficult time.
• "What would your family think about your drinking?

1. A nurse is reinforcing teaching with a client who is experiencing acute mania and has a prescription for lithium. Which of the following information should the nurse include?

• "Restrict your fluid intake to 1,400 milliliters per day."
• "Eat a low-sodium diet."
• "Avoid using diuretics."
• "Take lithium 2 hours before eating."

1. A nurse is caring for a client who returns late to the unit after being on a day pass. The client has slurred speech, an unsteady gait, and the scent of alcohol on her breath. Which of the following therapeutic responses should the nurse make?

• "I would like to discuss what happened today. We will talk in the morning,"
• "I don't understand why you were not more responsible with your day pass."
• "Why are you returning 3 hours late from your day pass?"
• "How much did you drink? You know drinking is against rules."

1. A nurse is working with a group client during group therapy. For which of the following clients disorder will setting limits severe as an appropriate behavioral management technique?

• Antisocial personality disorder.
• Delirium
• Generalized anxiety disorder
• Depression

1.  A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

• Hypomagnesemia
• Lanugo
• Hypokalemia
• Muscle wasting

1. A nurse is preparing to discharge a client who has depression. Which of the following information should the nurse plan to reinforce with the client regarding relapse?

• "Try snapping a rubber band on your wrist when depressive thoughts occur."
• "You should identify how you react to stressful events."
• "Your antidepressant medication will you feel better in a few days."
• "Use systematic desensitization to help prevent relapse."

  16. A nurse is collecting data from a client who has been admitted with manifestation of paranoia.  Which of the following findings should the nurse identify as a risk factor for schizophrenia? 

• The client's mother used tobacco products during pregnancy.
• The client's twin sibling has schizophrenia.
• The client's home has led on the walls.
• The client's is opioid dependent.

17.A nurse is collecting data from a client who has major depressive disorder and a new prescription for bupropion. Which of the following findings should the nurse identify as a contraindication for this medication?

• The client has an allergy to peanuts.
• The client has a seizures disorder
• The client has asthma.
• The client smokes two pack of cigarettes per day.

18. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client, there are three tabs that contain separate categories of data,)

• Blood glucose level
• Blood pressure
• WBC count
• temperature

EXIHIBIT 1 MEDICATIONS ADMINISTRATION

Clozapine 200 mg twice a day, Docusate sodium 100 mg PO twice daily with meals, Acetaminophen 500 mg 1 to 2 tablets PO every 4 hr PRN pain.

EXHIBIT 2 DIAGNOSTIC RESULTS.

WBC count 7,500/mm3, platelets 1500,000/mm3, Hct 42% , Blood glucose 200 mg/dL

EXHIBIT 3 GRAPHIC RECORD

Blood pressure 110/68 mm Hg, heart rate 68/mm, Respiratory rate 16/min, Temperature 37.8 C (100 F)

19. A nurse is reinforcing teaching with a client who has generalized anxiety disorder about nonpharmacological methods to manage anxiety. Which of the following instructions should the nurse include?

• "When you feel anxious, limit yourself to 10 minutes to focus on negative thoughts."
• "Spend time alone when you feel your anxiety escalating." 
• "You should discuss the use of electroconvulsive therapy with your provider."
• "When you begin to have anxious thoughts, say "stop!" out loud."

20. A nurse is caring for a client who has a new prescription for lithium, which of the following should the nurse monitor during treatment?

• Triglyceride 
• Blood glucose
• Oxygen saturation 
• Sodium

21. A nurse is caring for a client who was voluntarily admitted to an acute mental health unit and asks, "You aren't going to make me take medication, are you?' which of the following responses should the nurse make?

• "I can make a list of the medications that you don't want to take."
• "You agreed to take medication when you decided to be admitted."
• If the provider prescribes medication, I will have to administer it."
• "You have the right to refuse to take the medication."

22.  A nurse is caring for several clients on an inpatient mental health unit. Which of the following actions demonstrates that the nurse is following the ethical principles of veracity?

• Respecting client's right to refuse to take her medication
• Spending extra time with a client who has difficulty sharing her thoughts
• Being honest with a client about his plan of care
• Providing high-quality care for a client regardless of his personal background.

23. A nurse in a long-term care facility is caring for an older adult client who has dementia and is at high risk for falling. The client continuously attempts to get out of bed. Which of the following actions should the nurse take?

• Encourage the client to nap before the evening meal.
• Place the client's mattress on the floor of the room.
• Request a prescription for eszopiclone to administer each morning.
• Keep restraints on the client during the overnight hours.

24. A nurse is collecting data from a new client. Which of the following questions should the nurse include when determining the client's psychosocial status?

• "How old were you when you started your menses?"
• "Do you have medical insurance?'
• "Who do you talk to when you are upset?"
• "When did you last have a mammogram?'

25. A nurse is contributing to the plan of care for a client who is experiencing severe alcohol withdrawal. Which of the following interventions should the nurse contribute to the plan of care?

• Implement seizure precautions.
• Ambulate the client three times daily.
• Increase the temperature in the client's room.
• Administer benztropine.

26. A nurse is assisting with a community health education and support service for individuals who have lost loved ones to suicide. Which of the following actions should the nurse take when caring for these individuals? 

• Refer to the deceased person as the client, not the individual.
• Recommend that the individual wait at least 3 months before joining support group.
• Wait until the individual talks about their deceased loved one before mentioning their name.
• Ask open-ended questions when talking to the individual about their grief.

27. A nurse is preparing to administer risperidone 5 mg PO daily divided into two equal doses. Available is risperidone 0.5 mg tablets. How many tablets should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

28. A nurse is caring for a young adult client who has major depressive disorder and has been legally incompetent. The client requires informed consent for abdominal surgery. The nurse should recognize that which of the following people can consent to the surgery?

• The client's psychiatrist
• The client 
• The client's friend who visits daily
• The client's appointed guardian.

29. A nurse caring for a client who has terminal cancer and is receiving palliative care. Which of the following statements indicates that the client is demonstrating effective coping?

• "I should start making my funeral arrangements."
• "I need to return to work as soon as my treatment is complete."
• "I still believe my cancer will go into remission."
• "I hope to have surgery to cure my cancer.

30. A nurse is reinforcing teaching with a client who is grieving the recent loss of their partner. Which of the following interventions should the nurse make?

• Use sympathy to develop a trusting relationship with the client.
• Encourage the client to talk about the death of their partner.
• Advise the client to maintain the daily routine they shared with their partner.
• Inform the client that the acute phase of the grief process should last at least 6 months.

31. A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

• A client who has borderline personally disorder and acts impulsively.
• A client who has dependent personality disorder and clings to nursing staff
• A client who has avoidant personality disorder and becomes anxious in social situations
• A client who has histrionic personality disorder and seeks constant attention

32. A nurse is collecting data for a health history from the parent of an adolescent who has oppositional defiant disorder. which of the following manifestations should the nurse expect the parent to report?

• Bullies siblings and peers
• Sets destructive fires
• Often argues with adults
• Exhibits cruelty to animals

33. A nurse is collecting data from a client who has a new diagnosis of schizophrenia. Which of the following client statements supports this diagnosis?

• "Remember where I put things has become difficult/"
• "I just need a couple of hours of sleep each night."
• "I won't eat because I know that the food has been poisoned."
• "Counting stairs helps me feel more in control."

34. A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

• Explain the use of response prevention to the client
• Calculate the client's score on the Hamilton rating scale for anxiety.
• Discuss the benefits of relaxation exercise with the client.
• Administer an antianxiety medication.

35. A nurse is reviewing the laboratory results of a client who has anorexia nervosa. Which of the following results should the nurse report to the provider?

• WBC count 6,000/mm3
• HbA1c 4%
• Potassium 2.8 mEq/L
• Sodium 138 mEq/L

36. A nurse is caring for a client who has major depressive disorder and tells the nurse that, although they are feeling better, their future still looks bleak. Which of the following interventions is the nurse's priority?

• Assist the client to evaluate positive and negative life experiences.
• Use open-ended questions to encourage the client to express their feelings.
• Spend scheduled periods with the client during the day.
• Determine if the client has any plans to harm themselves.

37. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following information about the client is the priority for the nurse to collect?

• Ability to focus on a task
• Support system
• Communication style
• Hours of sleep per night

38. A nurse is reviewing the laboratory results for a client who has been taking lithium 6 months. Which of the following actions should the nurse take if the client's lithium value is 1.0 mEq/L?

• Suggest to the provider that the medication be decreased.
• Administer the medication.
• Suggest to the provider that the medication be increased.
• Withhold the medication.

39. A nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infection. Which of the following findings indicates that the client is developing delirium?

• Pale, dry skin
• Decreased blood pressure
• Disorganized thinking 
• Pinpoint pupils

40. A nurse is assisting with a staff education session about legal issues affecting the care of clients who have mental health diagnoses. Which of the following examples should the nurse identify as libel?

• Administering an incorrect dosage of a client's medication
• Threatening to apply restraints on a client's who is refusing medication
• Documenting false information about a clients' substance use history
• Taking the clothes of a client who is voluntarily admitted so that he cannot leave

41. a nurse is reviewing the plan of care for an older adult client who is oriented during the day but has  recently become confused at night, which of the following interventions should the nurse recommend to update the client's plan of care?

• Advise family members not to visit the client after the evening meal.
• Recommend a stimulating activity when the client become confused.
• Request a PRN prescription for an antianxiety medication.
• Transfer the client to a private room away from the nurse's station.

42. A nurse is assisting in teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barrios to learning?

• Assist the client in establishing long-term goals.
• Ensure the teaching sessions occur right before bedtime
• Use "I" statements rather than "you" statements.

43. A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• "A provider may speak to a client's employer regarding substance use disorder."
• "The provider must give consent to discuss health information with the client's family."
• "A client retains the legal right to privacy of health information even after they have died."
• "I can discuss a client's information with staff who have provided care in the past.

44. A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attends to first?

• A client who is standing in her room, yelling obscenities and throwing her clothes.
• A client in the dayroom who is screaming at other clients about what is on television.
• A client who is repeatedly approaching the nurse's station to request medication for his anxiety.
• A client who has bipolar disorder and is continuously pacing at the end of the hall.

45. A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?

• Tell the sibling the client does not want visitors.
• Arrange for the siblings to visit the client in the dayroom.
• Encourage the client to visit with the sibling.
• Refer the sibling to the client's provider.

46. A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescription for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?

• Documents the client's behavior every 2 hr.
• Implement 24-hr one-to-one nursing observation.
• Administer prescribed medication vis the IM route.
• Restrict interactions with other clients.

47. A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of the maturational crisis?

• Motor-vehicle crash
• Divorce
• Loss of job
• A child is leaving for college.

48. A nurse is caring for a client who has a new diagnosis of cancer. The client states, "I can't think about my health until after my son is married next week. The nurse should identify the client's statement as an indication of which of the following maladaptive defensive mechanisms?

• Suppression
• Projection
• Reaction formation
• Splitting

49. A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse," This baby constantly cries. My partner works all the time, and I can't take anymore. "Which of the following responses is the nurse's priority?

• Have you discussed this with your partner?"
• Having a newborn must be stressful. Do you have other children?"
• Tell me about your baby. Where is she now?"
• Do you have a friend who could help you?"

50.  A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregivers reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?

• Encourage the client to nap during the day.
• Place a lock at the top of doors leading outside.
• Administer an antianxiety medication before bedtime.
• Use light restraints while the client is in bed.

51. A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?

• Identify if the client has thoughts of self-harm.
• Encourage the client to use personal support systems.
• Reinforce teaching on the client's use of coping skills.
• Assist with a client referral for social services.

52. A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following statements should the nurse plan to take?

• Use an overly friendly approach.
• Be vague when answering the client's questions about instructions.
• Demonstrate a neutral demeanor.
• Ask the client why he is suspicious of others.

53.  A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?

• Diazepam 
• Buprenorphine
• Chlordiazepoxide
• Phenobarbital

54. A nurse is assisting with screening for a child abuse at a preschool. Which of the following factors place a child at risk for abuse?

• Autism spectrum
• First-born child
• Bedwetting
• Acute bronchitis

55. A nurse is assisting with a client in the dayroom. The client jumps up and states, 'there are snakes coming toward me!" which of the following responses should the nurse make?

• "I understand that you're seeing snakes, but I don't see any."
• "Would you like to play cards?"
• "Let's move to a different room to avoid the snakes."
• "What do you usually do when this happens?"

56. A nurse at a mental health clinic is caring for an adolescent client who has posttraumatic stress disorder following a violent episode with a stranger. Which of the following actions should the nurse take?

• Ask the client's guardian to go to another room during counseling sessions.
• Encourage the client to use guided imagery to decrease anxiety.
• Instruct the client to avoid expressions of anger and fear related to the episode.
• Direct the client to use regression to cope with the stress caused by flashbacks.

57. A nurse is caring for a client who stays in bed, is withdrawn from his surroundings, and rarely speaks. Which of the following is an appropriate statement for the nurse to make?

• "I would like to sit with you for a while."
• "It is such a beautiful day outside. And you're going to miss it."
• "I know you feel bad, but everything will be okay if you will get out of bed."
• "Our unit policy requires clients to get out of bed each day."

58. A nurse in a mental health facility is caring for a client who reports suicidal thoughts. Which of the following actions should the nurse take?

• Close the client's door when leaving the room.
• Ask the client to sign a no-harm contract.
• Check the client's mood every hour.
• Assign the client to a private room.