Nursing A Nurse in The Emergency Department Exam Practice

1. A nurse is caring for a client who is prescribed amitriptyline. The nurse should monitor the client for which adverse effect? a. Orthostatic hypotension b. Drooling c. Diarrhea d. Metallic taste in mouth 2. A nurse in the emergency department is caring for a client who attacked random strangers with a bat. The client refuses to be admitted for psychiatric treatment. Which statement is true regarding the mission of this client? a. The client can be admitted voluntarily by a family member. b. The client can be admitted involuntarily with a petition and certificate. c. The client can be admitted involuntarily and out against medical advice. d. The client has the right to refuse admission for psychiatric treatment. 3. The nurse is caring for a client that is in crisis and states that they “use alcohol to take the edge off.” Which nursing diagnosis is best to include in the plan of care?” a. Situational low self-esteem. b. Ineffective coping. c. Disturbed sleep. d. Spiritual distress 4. A nurse is educating a client about a new prescription for bupropion. Which statement by the client indicates the need for further education? a. “This medication is safe to take while breast/chestfeeding.” b. “I should limit my alcohol intake while taking this medication.” c. “This medication is best to take at night due to drowsiness.” d. “I should see full benefit in my mood within one week.” 5. A nurse has been assigned to care for a client diagnosed with major depression. Which nursing action aligns with the working phase of relationship building? a. Assist the client to facilitate change. b. Greet the client and introduce self. c. Summarize the goals achieved. d. Prepare the client assignment. 6. A nurse is caring for a client with conversion disorder who is suddenly unable to walk. The nurse recognizes that this symptom is most likely related to which cause? a. This is an expected outcome of the disorder. b. This is an adverse effect of the medication. c. This client is faking their symptoms. d. The client is responding to a stressor or anxiety. 7. A male client asked the nurse how they can become less aggressive. What is the nurse’s best response? a. “Males are more aggressive than females due to their increased testosterone.” b. “Try to suppress the expression of your emotions to reduce aggressive actions.” c. “Searching medications can promote assertive communication decreasing aggression.” d. “Keeping an anger diary can help identify your triggers that lead to aggression.” 8. A nurse is completing an admission assessment on a client who has a history of depression with a recent suicide attempt. During the assessment the client tells the nurse, “I should have died. I have always been a failure, and I have failed at this. Nothing ever seems to go my way.” Utilizing therapeutic communication, which is the best response by the nurse? a. “Why did you say you are a failure.” b. “You have so much to live for.” c. “That is a normal feeling for those that have a history of depression.” d. “Tell me more about your ongoing feelings of failure.” 9. A nurse is preparing to administer benztropine 1.5 mg intramuscular every 12 hours to a client experiencing an extrapyramidal reaction. Available is benztropine 1mg/mL for injection. How many mL(s) should the nurse administer per dose? 1 mL (if needed, round the answer to the nearest tenth). Answer: 10. A nurse is planning discharge education for a client with bipolar disorder going home with a prescription for lithium. What factor(s) that can contribute to lithium toxicity should the nurse include in the education? Select all that apply. a. Moderate exercise b. Sodium intake increase c. Diarrhea d. Dehydration e. Diuretics 11. A nurse in a mental health facility is caring for a client who suddenly becomes angry and throws a chair. Which action should the nurse perform first? a. Place the client in a monitored seclusion room until they are calm. b. Glance around the room to ensure the other clients are safe. c. Administer as needed anti-anxiety medicine as prescribed. d. Remain calm and attempt to speak with the client. 12. A nurse is caring for a client who is displaying aggressive behaviors. Which interventions should the nurse implement? Select all that apply. a. Apply wrist restraints. b. Allow the client to take control of the situation. c. Assist the client to an area that is quiet. d. Maintain a safe distance from the client. e. Acknowledge the client’s behavior. 13. A nurse is starting a plan of care for a client who describes themselves as being “anxious and depressed” after a recent job loss. What principle of stress and adaptation should the nurse integrate into the client’s plan of care? a. Stress is a part of everyday life, and eventually, everyone adapts. b Adaption often fails during stressful events and results in homeostasis. c. Anxiety and depression can be adaptations that alleviate stress in some individuals. d. Life stressors can disrupt emotional and physical homeostasis and result in illness. 14. A client is brought to the emergency department after lacerating both wrists. Which action should the nurse perform first? a. Administer an anti-anxiety medication. b. Assess and treat the client’s wrists. c. Record a detailed health history. d. Encourage the client to express their feelings. 15. A nurse is caring for a client with bipolar disorder who takes valproic acid. Which finding should be reported to the provider immediately? a. Jaundice b. Drowsiness c. Nausea d. Tremors 16. A nurse is planning a unit orientation for a newly admitted client with severe depression. Which is the best approach by the nurse? a. Have the client attend group therapy immediately. b. Sit with the client and offer simple, direction information. c. Explain the unit policies to the client and answer any questions that are asked. d. Take the client on a tour of the unit and provide introductions to all the staff members on duty. 17. A nurse is caring for a client to prescribe risperidone. Which assessment findings would indicate the client was experiencing an adverse reaction to the medication? Select all that apply. a. Weight gain of 30 pounds b. Stooped posture and shuffling gait c. Dry mouth d. Low prolactin level e. Dizziness upon standing. 18. A nurse is caring for a client with mental illness who is refusing treatment. Which ethical principle should guide the nurse’s actions? a. Autonomy b. Beneficence c. Non-maleficence d. Justice 19. A client has missed three consecutive physical therapy appointments due to complaints of either nausea, headaches, or chest pain. Which defense mechanism is this client exhibiting? a. Suppression b. Somatization c. Projection d. Dissociation 20. A nurse is caring for a client with major depressive disorder. The client attended cognitive behavioral therapy (CBT) group yesterday and states “I don’t think that g4roup is helpful.” Which statement(s) by the nurse would be therapeutic? Select all that apply. a. “CBT is not for everyone; I can understand why you are frustrated.” b. “CBT can help your medications work more effectively.” c. “CBT can help with your negative thinking which may improve your mood.” d. “CBT is helps reframe thinking to help with unhealthy behavior.” e. “CBT is mostly for clients with a cognitive impairment.” 21. A nurse is preparing to administer benztropine 2 mg IM every 12 hours. Atropine benztropine 1 mg per 1 mL for injection. How many mL should the nurse administer per dose? mL (if needed, round answer to the nearest whole number) Answer: 22. A nurse is providing education to a client about phenelzine. Which of the following should the client be instructed to avoid? select all that apply. a. Selective serotonin reuptake inhibitor (SSRI) medications b. Aged Parmesan c. Pepperoni pizza d. Milk e. Over-the-counter medications 23. The nurse documents assessment findings of a client who is unable to recall all specifics related to compound childhood traumas. Which disorder is the client experiencing? a. Selective amnesia b. Localized amnesia c. Generalized amnesia d. Retrograde amnesia 24. A nurse is planning care for a client who is extremely suspicious of the nursing staff and other clients. Which approach(es) should the nurse include to use when establishing a therapeutic relationship with this client? Select all that apply. a. Give the client their phone number to demonstrate availability. b. Ask the client if it’s OK before touching them. c. Bring the client small gifts each day to earn their trust. d. Adopt A neutral, non-threatening attitude when providing care. e. Promote an honest relationship and keep promises made to the client. 25. A nurse is planning education for a client with a new prescription for an antipsychotic medication. Which instruction is most important for the nurse to include in the teaching? a. Avoid alcohol and sedative medications. b. Eat a low-calorie diet. c. Avoid excessive exposure to sun. d. Use sugar-free gum or candy. 26. A nurse is caring for a client with schizophrenia who is taking haloperidol. The nurse should monitor the client for which adverse effect? a. Extrapyramidal symptoms b. Fever c. Intractable hiccups. d. Excessive salivation 27. A nurse is planning education for a client taking lithium. Which statement is a priority for the nurse to include in the teaching? a. “If you experience diarrhea, stop taking this medication immediately.” b. “Remember to take this medication on an empty stomach.” c. “You will need to return to the clinic to have your blood levels drawn in 6 weeks.” d. “Remember will need to avoid salt in your diet while taking this medication.” 28. A nurse is caring for a client who is admitted voluntarily to a mental health unit. The nurse places the client in physical restraints when they become verbally abusive and demand to be discharged. Which possible legal ramification(s) would be associated with placing the client in restraints. Select all that apply. a. Libel b. False imprisonment c. Assault d. Slander e. Battery 29. A nurse is providing education to staff members about working with clients who have a history of anger and aggression. Which of the following should the nurse include in the education? Select all that apply. a. Only wear items around your neck that have a breakaway latch. b. Provide immediate feedback for escalating behavior. c. Stand in front of the client when talking. d. Call security for all client interactions. e. Do not stand in a corner when talking with the client. 30. A nurse in an urgent care clinic is assessing a client who has a history of anxiety disorder and reports chest pain, headache, and shortness of breath. The client continues to verbalize to the nurse that they do not know why their spouse left them. The nurse recognizes that the client’s symptoms support which level of anxiety. a. Mild anxiety b. Moderate anxiety c. Severe anxiety d. Panic Anxiety 31. A nurse is educating a client about their new prescription for zolpidem. The nurse should advise the client about which adverse effect? a. Daytime sleepiness b. Nighttime sweating c. Change in taste d. Double vision 32. A nurse is caring for a client diagnosed with illness anxiety disorder, which expected findings supports this diagnosis? a. The client avoids care with health care providers. b. The client demonstrates no concern despite neurological manifestations. c. The client purposely causes injury or illness to a vulnerable person. d. The client rarely examines self for health-related problems. 33. A nurse enters the room of a client who is being verbally abusive. Which action should the nurse take when caring for this client? a. Use a firm and slow voice when speaking. b. Use negative reinforcement when they stop. c. Apologize to client for arguing. d. Ask them to stop yelling and calm down. 34. A change nurse provides education to a new nurse on common crisis characteristics. Which statement by the new nurse indicates the need for further education? a. “The client’s loss the event as overwhelming.” b. “The client exhausts may be actual or perceived.” c. “The client experiences sudden events with little or no time to prepare.” d. “The client possesses effective coping mechanisms.” 35. Which statement by provider indicates an understanding regarding dissociative identity disorder (DID)? a. “I suspect my client inherited this disease from their parent.” b. “It is unlikely my client has a diagnosis of schizophrenia before DID, since the two do not go hand in hand.” c. “My clients experiences periods of blackouts, or lost time where they do not know what happened during that time frame.” d. “If I assume my client has other personalities because they do not want to deal with real life.” 36. A nurse is educating a client with a dissociative disorder about predisposing factors. Which statement by the client indicates a need for further education? a. “I may have a dissociative disorder because it runs in my family.” b. “This disorder may be due to repressed stressors.” c. “Dissociative disorders may occur due to abuse.” d. “Dissociative disorders may be associated with alterations in serotonin levels.” 37. A change nurse provides education to new nurses on interventions for the client experiencing a crisis. Which statement by the new nurse indicates further teaching is required? a. “I can utilize therapeutic communication to help this client.” b. “Operant conditioning can prove helpful for this client.” c. I expect a multi-disciplinary approach to meet client needs, such as housing and employment.” d. Anxiolytics may be prescribed to this client.” 38. A nurse is providing discharge education to a client who is taking risperidone. Which instruction should the nurse include in the teaching? a. Get adequate sunlight. b. You may continue driving as well. c. Avoid foods in high potassium. d. When changing positions, make sure you move slowly. 39. A nurse is providing education to a client prescribed lorazepam. Which client statement indicates further education is required? a. “This medication can be addictive.’ b. “I should not drink alcohol while taking this medication.” c. “I cannot stop this medication abruptly.” d. “I can expect to take this medication for years.” 40. A manager is preparing a presentation on the need for physical restraints for some clients. Which example should the nurse manager use in the presentation? a. A client with limited internal control over their behavior needs external controls firm and consistent limit-setting. b. A client with poor boundaries does not respond to verbal redirection and needs firm and consistent limit-setting. c. A client with antisocial tendencies needs external controls to submit to the staff members’ authority. d. A client who has behavioral dysfunction and strict limits and behavioral interventions. 41. A psychiatrist nurse is conducting a mental status exam on a client. Drag and drop the components that are included in a mental status exam into the box titled Components of a material status exam. Possible components Thought process Speech Treatment history Substance abuse Mood Components of a Mental Status Exam Appearance 42. A nurse is caring for a client who refuses to take medication, citing the right of autonomy. Under which circumstance(s) would a nurse have the right to medicate the client against the client’s wishes? Select all that apply. a. A client verbalizes intent to cause physical harm to self or others. b. A client refuses to take a shower in the morning. c. A client makes inappropriate comments to a staff member. d. A client physically attacks another client. e. A client aggressively grabs a nurse in demands sexual favors. 43. A nurse is caring for a client who is experiencing anxiety as a result of a crisis. Which actions should the nurse implement? Select all that apply. a. Assess for suicidal thoughts. b. Remain with the client to ensure safety. c. Determine support system. d. Prioritize physical needs. e. Reassure the client that life will improve. 44. A nurse is preparing to administer olanzapine 20 mg by mouth daily. Available is Olanzapine 10 mg orally disintegrating tablets. Oh. How many tablets should the nurse administer per dose? 1 tab (if needed, round the answer to the nearest whole number.) Answer: 45. A nurse is reviewing medications for a newly admitted client experiencing mania. Which medication will reduce the client’s mania? a. Fluvastatin b. Carbamazepine c. Lorazepam d. Propranolol 46. A nurse is caring for a client with a mental health disorder, which action by the nurse best reflects the establishment of a therapeutic relationship with the client. a. Encouraging the client to participate in group therapy sessions. b. Providing the client with educational materials about their disorder. c. Allowing the client to set their own goals for care and collaborating on a plan. d. Administering medications as prescribed without explanation. 47. A nurse is caring for a client who is having acute alcohol withdrawal and is attempting to harm other clients and staff. Which action should the nurse take first? a. Place the client in restraints b. Call the health care provider. c. Administer chlordiazepoxide. d. Initiate one to one observation 48. A nurse is caring for a client experiencing sudden blindness without physiological cause. The client shows no concern about this new deficit. What is the best explanation for the client’s reaction? a. La belle Indifference b. Illness anxiety disorder c. Factitious disorder d. Depersonalization 49. A nurse is involved in systematic desensitization therapy for a client who has a fear of crowds. Which step of the process of systematic desensitization should the nurse anticipate to be initiated first? a. Expose the client to the fear and incremental steps. b. Develop a schedule with the client to practice exposure to fear. c. Identify the specific stimulus cues that cause the client to react. d. Instruct the client to prioritize which stage of fear causes the most anxiety. 50. The nurse is caring for a group of clients in a mental health facility. Which client(s) should the nurse identify as appropriate for an involuntary commitment? Select all that apply. a. A client verbalizing intends to commit suicide. b. A client refusing to take a shower. c. A client living under a bridge in a cardboard box. d. A client verbalizing intent to harm others. e. A client who eats waste out of a garbage can. 51. The nurse is educating a client on the goals of cognitive behavior therapy. Which statement(s) by the client would indicate the education was successful. Select all that apply. a. It promotes the identification of connections between thoughts. b. It examines evidence related to thought distortion c. It helps to promote and enhance personalization. d. It helps to monitor negative, automatic thoughts. e. It teaches individuals how to do a time-out. 52. A nurse is preparing a client for electroconvulsive therapy (ECT). Which finding in the client’s medical record indicates the client is at a higher risk for complications related to this therapy? a. Cerebrovascular accident 2 weeks ago. b. Diagnosis of schizophrenia. c. History of anxiety. d. Current medications include phenytoin. 53. A nurse is caring for a client who has a prescription for diazepam IV in 3 divided doses. The client weighs 121 pounds. The healthcare provider prescribes. 0.5 mg/kg/day in 3 divided doses. How much should the nurse administer per dose? 1 mg (If needed, round the answer to the nearest tenth.) Answer: 54. a nurse is caring for a client who just left a therapeutic group session. The client states “I hate going to the group therapy, there is no reason for me to go.” Which responses by the nurse would be considered therapeutic? Select all that apply. a. “It sounds like you are frustrated.” b. “What I hear you saying is that you feel that group sessions are not helping.” c. “Tell me more about how you feel when you are in group sessions.” d. “Why don’t you like the group sessions?” e. “You know there are many reasons for your group therapy.” 55. The nurse observes a fellow nurse administer an extra unauthorized dose of a benzodiazepine to an agitated client. What should the nurse do first? a. Notify the nurse manager. b. Assess the client. c. Confront the nurse. d. Submit an incident report. 56. A nurse confronts a maniac client who has been making sexual advances toward visitors. The nurse firmly states that the behavior is inappropriate, but the client threatens physical violence toward the nurse. Which action should the nurse implement next? a. Place the client in a separation seclusion room. b. When the client that there will be consequences. c. Gain assistance from staff to walk the client to their room. d. Revoke the clients telephone privileges. 57. The emergency department nurse manager prepares a plan for incidents involving violent outbursts or physical violence. What should the nurse manager include in the plan? Select all that apply. a. Hold debriefing sessions on the shift that the violence occurred. b. Coordinate with security staff on emergency assistance protocols. c. Allow the staff to voice feelings and concerns related to the incident. d. Educate staff to recognize early pre-assaultive signs in client behavior. e. Designate a separate area to hold clients waiting to transfer to behavioral health. 58. A nurse is conducting an assessment for a client with schizophrenia who has been treated with fluphenazine for several years. Which finding should alert the nurse to manifestations of tardive dyskinesia (TD)? a. Tremors b. Akathisia c. Sudden onset of high fever d. Sudden involuntary jerking movements 59. A nurse provides education to a client who has been prescribed buspirone for generalized anxiety disorder. Which statement(s) should be included in the client teaching? Select all that apply. a. “Buspirone lacks the sedative effects associated with other anxiolytics.” b. “Buspirone should be taken at the onset of anxiety.” c. “Buspirone is non habit forming.” d. “Buspirone works extremely fast.” e. “Buspirone is indicated for long-term treatment of anxiety.” 60. A nurse is reviewing the medication administration record for a client with schizophrenia who is prescribed clozapine. Which finding indicates a contradiction to the medication? a. Chronic Hypertension. b. Granulocytopenia c. Hypoglycemia. d. Bronchitis 61. A nurse is instructing the parents of a child with attention deficit hyperactivity disorder (ADHD) about methylphenidate. Which statement should the nurse include in the instructions? a. “Administer the medication at bedtime.” b. “Your child might gain weight while taking this medication.” c. “This medication might increase the amount of saliva your child produces.” d. “Restrict your child’s intake of caffeine while taking this medication.” 62. A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20mg/5mL. How many mL should the nurse administer? 1 mL (if needed round the answer to the nearest whole number.) Answer: 63. A nurse is educating a client about their new prescription for sertraline. Which statement by the client indicates to the nurse a need for further teaching? a. “It might take a month for the medication to be effective.” b. “I can stop taking the medication once I feel better.” c. “I might have a hard time sleeping with this medication.” d. “I might need to get labs drawn.” 64. A newly admitted client tells the nurse, “I’m not attending these group meetings. I’m here to get some rest. Which is the best response from the nurse. a. “The health care provider mandates group therapy. All clients must attend.” b. “Group therapy provides the opportunity to develop new coping skills.” c. “You only have to go to the group meetings that are meaningful to your diagnosis.” d. “We provide group therapy so that clients can interact with each other.” 65. A nurse receives handoff report for four clients. Which client should the nurse assess first? a. A client who is prescribed trazodone reports feeling tired in the morning. b. A client who was really recently prescribed lorazepam and reports feeling tired. c. A client who is prescribed sertraline with a sodium level of 136 mEq/L. d. A client who is prescribed clozapine and reports a sore throat with a temperature of 99.7 F. 66. A nurse is providing care for a client who confides in them about having harmful intentions towards a family member. The nurse believes there is a clear risk of harm to the family member. What is the nurse’s legal and ethical responsibility in this situation? a. Respect the client’s confidentiality and maintain trust by keeping the information confidential. b. Inform the client’s family members to protect and involve them in the decision-making process. c. Seek consultation with a health care team member to determine the appropriate course of action. d. Notify the health care team to ensure the family member is notified, as required by the duty to warn principle. 67. A nurse is providing education to a client with schizophrenia and a new prescription for fluphenazine. Which information should the nurse provide? a. “This medication might turn your urine orange.” b. “Sleepiness should subside within a week.” c. “Stop the medication if hypertension occurs.” d. “A low-grade fever is expected with the first dose.” 68. A nurse is transitioning to psychiatric nursing. Which are common nursing actions in mental health? Select all that apply. a. Crisis intervention b. Individual therapy facilitation c. Milieu management d. Medication administration e. Therapeutic communication 69. The family of a client diagnosed with conversation disorder asked the nurse, “Will their paralysis ever go away.” Which is the best response by the nurse? a. Most symptoms of conversation disorder resolve within a few weeks.” b. “Typically, conversation disorder symptoms stay with the client for life.” C. “Recovery cannot happen without treatment.” d. “There is nothing physically wrong with the client, it is in their head.” 70. A nurse witnesses two clients participate in a physical altercation in the milieu. Which ethical principle guides the nurse to apply equal treatment to these clients for breaking the rules of the milieu? a. Justice b. Beneficence c. Nonmaleficence d. Veracity

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