A nurse is caring for a school aged -child who has conduct disorder and is being physically aggressive to other children on the unit. Which of the

 

   

1. A nurse is caring for a school aged -child who has conduct disorder and is being physically aggressive to other children on the unit. Which of the following actions should the nurse take first?

A. Place the child in seclusion

B. Use a therapeutic hold technique.

C. Apply wrist restrains.

D. Administer risperidone.

2. A nurse is caring for a client who has a new diagnoses of bulimia nervosa. Which of the following diagnostic procedures should the nurse anticipate the provider to prescribe during the medical evaluation?

A. Chest x-ray

B. ECG

C. Coagulation Studies

D. Liver function

3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorder?

A. Dependent

B. Paranoid

C. Borderline

D. Histrionic

4. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

A. Inform the client that he does not have the right to refuse medication.

B. Administer the medication to the client via IM injection.

C. Offer the client the medication at the client schedule dose time

D. Implement consciences until the client takes the medication.

5. A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment which of the following actions the nurse plan to take next?

A. Conduct a pregnancy test

B. Request a mental health consultation for the client.

C. Provide a trained advocate to stay with the client

D. Offer prophylactic medication to prevent STIs

6. A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy(ECT) but will not sign the consent form. Which of the following actions should the nurse take?

A. Request that the client’s partner signs the consent

B. Cancel the scheduled ECT procedure.

   

C. Proceed with preparation for ECT based on implied consent

D. Inform the client about the risks of refusing ECT.

7. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he became angry and tells her to live. Which of the defense mechanisms is the client demonstrating?

A. Rationalization

B. Denial

C. Compensation

D. Displacement

8. A nurse is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which f the following statements by the nurse is appropriate?

a. “Please don’t take what the client said seriously when she is depressed.”

b. “It’s important that the client feels safe verbalizing how she is feeling.”

c. “Everybody feels that way about the client, so don’t worry about it.

d. “I’ll change your assignment to someone who doesn’t have depressive disorder.

9. A nurse is assessing a child in the emergency department. Which of the following findings places the child at greatest risk of physical abuse?

a. The child is 10 years old

b. The child is homeschooled

c. The child has no siblings

d. The child has cystic fibrosis

10. A nurse is providing behavioral therapy for a client who has obsessive- compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

a. “Keep a journal of how often you check the locks at night.”

b. “Snap a rubber band on your wrist when you think about checking the locks.”

c. “Ask a family member to check the locks for you at night.”

d. “Focus on abdominal breathing whenever you go to check the locks.”

11. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?

a. Bradycardia

b. Stupor

c. Afebrile

d. Hypertension

   

12. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

a. Weigh the client twice a day

b. Prepare the client for electroconvulsive therapy

c. Set a weight gain goal of 2.2 g (5 lb.) per week

d. Encourage the client to participate in family therapy

13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?

a. Readily initiates conversation

b. Enjoys imaginative play

c. Strong relationship with siblings and peers

d. Attachment to objects that spin

14. A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention?

a. Secure the client’s valuable possessions

b. Limit loud noises in the client’s environment

c. Encourage the client to participate in structured solitary activities.

d. Provide high-calorie snacks to the client.

15. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication?

a. Blocks aldehyde dehydrogenase

b. Prevents the anxiety of abstinence

c. Reduces substance craving

d. Decreases the likelihood of seizures

16. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms?

a. Repression

b. Rationalization

c. Introjection

d. Intellectualization

17. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?

a. “How does this situation affect your life?”

b. “Do you see your current situation affecting your future?”

c. “Can you describe how you are currently feeling?”

d. “How have you dealt with similar situations in the past?”

   

18. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time?

a. Contact the adolescent’s parents

b. Suggest the adolescent join a support group

c. Ask the adolescent if he is considering hurting himself

d. Determine when the adolescent’s change in behavior began

19. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?

a. Slurred speech

b. Hypotension

c. Bradycardia

d. Hyperthermia

20. A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

a. Lack of remorse

b. Attention-seeking

c. Splitting of staff

d. Identity disturbance

21. A nurse is providing teaching to the daughter of an older adult client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching?

a. “I will limit my mother’s clothing choices when she is getting dressed.”

b. “I will provide my mother with detailed instructions about how to perform self-care.”

c. “I will wake my mother up a couple of times in the night to check on her.”

d. “I will discourage my mother from talking about her physical complaints.”

22. A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following findings should the nurse expect?

a. Self-mutilation

b. Pacing back and forth

c. Preoccupation with details

d. Disorganized speech

23. A nurse is reviewing the laboratory results of an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

a. Blood glucose 100 mg/dL

b. T411 mcg/dL

c. Potassium 3.7 mEq/L

d. Hgb 10 g/dl

   

24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?

a. “This medication is given to help with extrapyramidal side effects.”

b. “This medication is given to help with your depression.”

c. “Benztropine helps alleviate your hallucinations.”

d. “Benztropine is used to counteract your tachycardia.”

25. A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan?

a. Reinforce the client’s orientation with a calendar.

b. Refute the client’s perception of visual hallucinations.

c. Teach the client assertive techniques.

d. Assign the client to a different caregiver each shift.

26. A nurse is creating a plan of care for a client who has a major depressive disorder. Which of the following interventions should the nurse include in the plan?

a. Discourage the client from expressing feelings of anger.

b. Identify and schedule alternative group activities for the client.

c. Encourage physical activity for the client during the day.

d. Keep a bright light on in the client’s room at night.

27. A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?

a. Encourage the client to suppress feelings of trauma.

b. Assign the same staff to care for the client each day.

c. Address the client in an authoritative manner.

d. Limit the amount of time spent with the client.

28. A nurse is providing teaching for a school-age child and his parent regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching?

a. “I will provide a low-sodium diet for my son.”

b. “I will make sure my son takes the last dose of the day by 4 p.m.”

c. “I should expect my son to develop hand tremors.”

d. “I should contact my doctor if my son urinates excessively.”

29. A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?

a. Withhold the next dose of lithium.

b. Repeat the lithium level test.

c. Administer the next dose of lithium.

d. Recommend a low-sodium diet

30. A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive- behavioral family therapy in response to which of the following client statements?

   

a. “I want to learn how to change the way I react to problems with my family.”

b. “I want to understand why my past experiences are affecting my family relationships.”

c. “I want to improve my family’s understanding of each other’s boundaries.”

d. “I want each of my family members to be more aware of each other’s feelings.”

31. 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)

a. Position the mattress on the floor

b. Install sensor devices on outside doors

c. Encourage physical activity prior to bed time.

d. Put locks at top of doors

e. Place the client in a reclining chair.

32. A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity?

a. Calcium 9.0 mg/dL

b. Sodium 130 mEq/L

c. Chloride 98 mEq/L

d. Potassium 5.0 mEq/L

33. A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

a. Contact the facility social worker to obtain the consent.

b. Explain implied consent to the client’s family.

c. Request that the client’s guardian sign the consent

d. Ask the charge nurse to obtain informed consent.

34. A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicated an understanding of the teaching?

a. “Survivors of abuse often feel guilty.”

b. “Abusers often have high self-esteem.”

c. “The honeymoon stage of violence usually gets longer over time.”

d. “As abuse continues, victims become more determined to be independent.”

35. A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?

a. The client joins a support group.

   

b. The client identifies techniques to reduce her stress.

c. The client develops a safety plan.

d. The client identifies support systems.

36. A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

a. Use projection during group therapy

b. Increase self-esteem

c. Use bargaining skills for behavioral consequences

d. Decrease the number of verbal outbursts

37. A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

a. Nausea

b. Random blood glucose 130 mg/dL

c. Heart rate 104/min

d. Sore throat

38. A nurse is counseling an adult client whose parent just died. The client states, “My son is 4, and I don’t know how he’ll react when he finds out that his grandpa died.” The nurse should inform the client that the preschool-age child commonly has which of the following conceptions of death?

a. Death is not permanent and the loved one may come back to life.

b. Death is contagious and can cause other people he loves to die.

c. Death creates an interest in the physical aspects of dying.

d. Death is a part of life that eventually happens to everyone.

39. A nurse is reviewing medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

a. Schizoid personality disorder

b. Alcohol intoxication

c. Dysthymic disorder

d. Long-term isolation

40. A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?

a. Request that the parent leave the room while interviewing the child.

b. Report suspected abuse to Child Protection Services.

c. Ask the child how the injury occurred.

d. Determine the immediate safety needs of the child.

41. An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routing activities. The daughter states, “I’m so worried

   

that my mother is depressed.” Which of the following responses should the nurse make?

a. “Older adults are usually diagnosed with depressive disorder as they age.”

b. “Everyone gets depressed from time to time.”

c. “You shouldn’t worry about this, because depressive order is easily treated.”

d. “Tell me the reasons why you think your mother is depressed.”

42. A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship?

a. Summarize goals and objectives

b. Address confidentiality.

c. Promote problem solving skills.

d. Establish a participation contract.

43. A nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head and says, “Please forgive me, I’m not sure what came over me! I don’t know why I said those things.” The nurse interprets this behavior as which of the following?

a. Emotional lability

b. Confabulation

c. Flight of ideas

d. Neologism

44. A nurse is providing teaching for the family of a client who has dementia. Which of the following should the nurse include in the teaching as a contributing factor for this disorder?

a. Hypotension

b. Alcohol use disorder

c. Dehydration

d. Change in environment

45. A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?

a. The client reports improved short-term memory.

b. The client has decreased euphoric mood.

c. The client reports absence of auditory hallucinations.

d. The client has decreased anxiety

46. A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the following information should the nurse include?

a. “This therapy works as a cure for major depressive disorders.”

b. “You will be awake and alert during the procedure.”

c. “You might experience confusion for a few hours after treatment.”

d. “This therapy will stimulate the vagus nerve to improve your mood.”

   

47. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take?

a. Ask the client if she has eaten foods containing tyramine.

b. Give regular insulin subcutaneously to the client.

c. Prepare the client for electroconvulsive therapy

d. Administer dantrolene IV bolus to the client

48. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider?

a. Urine specific gravity 1.029

b. Platelets 90,000/mm cubed

c. Urine pH 5.6

d. RBC 4.7/mm cubed

49. A nurse is caring for a client who has schizophrenia and started taking clozapine 2 months ago. Which of the following laboratory results should the nurse report to the provider?

a. WBC 3000/mm cubed

b. Potassium 4.2 mEq/L

c. Hgb 16 g/dL

d. Platelets 300,000/mm cubed

50. A nurse is assessing the boundaries of a client’s family. One of the family members says to the client, “I know exactly what you’re thinking right now.” The nurse should recognize that the family member is displaying which of the following types of boundaries?

a. Rigid

b. Inconsistent

c. Enmeshed

d. Clear

51. A nurse is assessing a client who requests bupropion for smoking cessation. Which of the following findings in the client’s history should the nurse recognize as a contradiction for taking this medication?

a. Seizures

b. Anemia

c. Migraines

d. Asthma

52. A nurse is caring for a client who has Alzheimer’s disease. Which of the following actions should the nurse take?

a. Seat the client at a dining table with six of more residents

b. Provide the client with several choices for meal selection

c. Give complete directions before starting client care

d. Use symbols to assist the client in locating rooms

53. A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?

a. Anhedonia

   

b. Waxy flexibility

c. Contractions of the jaw

d. Incongruent affect

54. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?

a. High fever

b. Insomnia

c. Urinary hesitancy

d. Headache

55. A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection?

a. “I would like to sit with you for a while.”

b. “You feel upset when this happens?”

c. “Let’s work together to try to solve your problem.”

d. “Can you tell me what is happening now?

56. A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

a. “I don’t know how I could cope if I didn’t have my family’s support.”

b. “It’ll be a long time before I’m happy again.”

c. “I don’t feel anything but numbness anymore.”

d. “I feel like I’m angry at the whole world right now.”

57. A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero)

   

a.   

  

12.5 mL

   

58. A nurse is teaching the parent of a school-age child who has ADHD and a prescription for atomexine 40 mg daily. Which of the following information should the nurse include in the teaching?

a. Expect the child to gain weight while taking this medication.

b. Crush the medication and mix it with 120 mL (4 oz) of juice.

c. Therapeutic effects will occur within 24 hours of starting treatment

d. Administer the medication before the child goes to school in the morning.

59. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?

a. Place the client in a group therapy session

b. Rotate staff members who work with the client

c. Encourage the client to participate in physical activities

d. Distract the client with increased environmental stimuli

   

60. A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide?

a. The client is married

b. The client is female

c. The client is 50 years of age

d. The client has diabetes mellitus

61. A nurse is performing a mental status examination for a client who has schizophrenia. The nurse should recognize that which of the following actions requires the client to think abstractly?

a. Explain what to do if he misses the bus.

b. Determine the meaning of a proverb

c. Name the last three presidents of the US

d. Count by adding sevens consecutively.

62. A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan?

a. Administer olanzapine

b. Institute consequences for deliberate behaviors

c. Provide a stimulating environment

d. Encourage thought stopping techniques

63. A nurse in a mental health facility is making plans for a client’s discharge. Which of the following indisciplinary team members should the nurse contact to assist the client with housing placement?

a. Clinical nurse specialist

b. Recreational therapist

c. Social worker

d. Occupational therapist

64. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client?

a. Encourage the client to display anger toward the cause of crisis

b. Tell the client that his life will soon return to normal

c. Identify the client’s usual coping style

d. Help the client focus on a wide variety of topics regarding the crisis

65. A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse take during the orientation phase?

a. Manage conflict within the group

b. Establish a rapport with group members

c. Encourage the use of problem solving skills

d. Maintain the group’s focus on identified issues

66. A nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the

  

following findings indicated that the client is at an increased risk for suicide?

a. Increased energy

b. Hypersomnia

c. Unkempt appearance

d. Psychomotor retardation

67. A nurse in a rehabilitation unit is caring for a client who has a  traumatic brain injury. To which of the following members of the client’s interprofessional team should the nurse refer the client in order to help him relearn how to use eating utensils?

a. Neuropsychiatrist

b. Occupational therapist

c. Physical therapist

d. Social worker

68. 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?

a. A client who reports that she took $20 from the cash register where she works

b. A client who reports that her partner ties their child to bed as punishment

c. A client who reports that he enjoys smoking marijuana on the weekends

d. A client who reports lying to his provider about having suicidal ideation

69. 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?

a. Recent head injury

b. Hepatitis B infection

c. Hypothyroidism

d. Knee arthroplasty 1 month ago

70. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms?

a. Suppression

b. Reaction formation

c. Identification

d. Compensation