1. A nurse is teaching about deep-breathing exerciseswith a client who reports experiencing intense stress at work. Which of the following statements by the client indicates an understanding of the teaching?A. “I will hold my breath for 5 or 6 seconds each time.”B. “I will focus on how the muscles in my stomach feel with each breath.”C. “I will focus on the causes of my stress during the exercise.”D. “I will inhale through my mouth and exhale through my noise.” 2. A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?A. Discourage the client forming new relationshipsB. Change the subject when the client becomes upsetC. Offer the client advice about various treatment choicesD. Allow the client unlimited time for the grieving process 3. A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take?A. Initiate facility procedures for emergency commitmentB. Inform the client about polices for dispensing methadone C. Request a prescription for varenicline from the client’s providerD. Assess the client using the CAGE naire 4. A nurse is caring for a school-age child who has conduct disorder and requires wrist restrains. Which of the following actions should the nurse take?A. Have the child perform range of motion exercises every 3 hrB. Obtain a prescription for the restraints within 2 hr of initiating them C. Monitor the child’s vital signs every 15 minD. Ensure three fingers will fit between the child’s wrist and the restraint 5. A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?A. Crohn’s diseaseB. HypothyroidismC. Seizure disorderD. Asthma 6. 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. NauseaB. Random blood glucose 130 mg/dLC. Sore throatD. Heart rate 104/min 7. A nurse is planning to conduct a supporting group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?A. Establish a rapport with group membersB. Maintain the group’s focus on identified issuesC. Encourage the use of problem-solving skillsD. Manage conflict within the group 8. A nurse is conducting an education class for a group of clients who have schizophrenia and a new prescription for clozapine. Which of the following statements by a client indicates an understanding of the teaching?A. “I should discontinue the medication if I have adverse effects.”B. “My symptoms will resolve in 4 days.”C. “I will need to have tab tests weekly for the first 6 months.”D. “I can still take my St. John’s work.” 9. A nurse is providing teaching for a client who has a new prescription for a monoamine oxidase inhibitor. Which of the following foods should the nurse instruct the client to avoid?A. GrapefruitB. YogurtC. SpinachD. Pepperoni 10. A nurse is developing a behavior contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?A. Decrease the number of verbal outburstsB. Use bargaining skill’s for behavioral consequencesC. Increase self-esteemD. Use projection during group therapy 11. A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?A. Negotiate with the client how much weight she should gain each weekB. Notify the client about designated times for mealsC. Decrease the client’s daily intake of fiberD. Weight the client weekly for the first month 12. A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?A. Decreased blood pressureB. Decreased heart rateC. HyperthermiaD. Hyperglycemia 13. A nurse is providing discharge teaching about medication administration to a client who has a prescription for lithium. Which of the following information should the nurse include in the teaching?A. “Take ibuprofen if you need to use a pain reliever.”B. “You will need to decrease your sodium intake.”C. “You should take the medication with meals.”D. “You should have your lithium levels checked every year.” 14. A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?A. Suggest the client make a list of things that make him angryB. Role model healthy ways to express angerC. Ask the client if he intends to harm othersD. Assist the client to explore techniques to reduce stress 15. A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child providers different accounts of the cause of the injury. Which of the following actions should the nurse take first?A. Determine the immediate safety needs of the childB. Ask the child how the injury occurredC. Request that the parents leave the room while interviewing the childD. Report suspected abuse to child protective services 16. A nurse is caring for a client who has a new prescription for citalopram. The nurse should recognize that this medication can result in an adverse interaction when taken with which of the following over-the-counter supplements?A. Fish oilB. St. John’s wortC. Saw palmettoD. Glucosamine 17. A nurse is caring for a client who has a prescription for escitalopram. Which of the following statements by the client indicates that the medication is having the intended effect?A. “I am no longer having hallucinations.”B. “My mood has improved over the last year.”C. “I am gaining weight steadily.”D. “My tremors have decreased significantly.” 18. A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?A. +2 edema of the lower extremitiesB. BUN 21 mg/dLC. Blood pH 7.60D. Lanugo covering the body 19. A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?A. Rapid mood swingsB. Impaired memoryC. Inappropriate speech patternsD. Command hallucinations 20. A nurse is caring for a client who has bordering personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following group?A. Co-dependents support groupB. Desensitization therapyC. Dual diagnosis treatment groupD. Dialectical behavior treatment group 21. A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings should the nurse expect?A. Rapid mood swingsB. Excessive motor activityC. Failure to recognize familiar objectsD. Altered level of consciousness 22. A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?A. “The client needs to accept responsibility for his substance use.”B. “The client generally shares his feelings during group therapy sessions.”C. “The client is just like my brother who finally overcome his habit.”D. “The client asked me to go on a date with him, but I refused.” 23. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to assistive personnel?A. Check the client’s condition after the procedureB. Give the client atropine 30 min before the procedureC. Assist the client to ambulate for the first time following the procedureD. Witness the client’s signature on the consent for the procedure 24. 25. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?A. A client who has bipolar disorder and its speaking loudlyB. A client who is taking lithium and reports weigh gainC. A client who has schizophrenia and is experiencing olfactory hallucinationsD. A client who is taking clozapine and reports a sore throat 26. A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client’s adherence to the treatment plan?A. The client’s potassium level is 3.2 mEq/LB. The client’s current BMI is 14C. The client states that she knows she can’t be perfectD. The client reports following various cooking blogs 27. A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity?A. WBC 6,000/mm3B. Sodium 132 mEq/LC. Calcium 10.0 mg/dLD. Aspartate aminotransferase 40 units/L 28. A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?A. Stop the newly licensed nurse from administering the medicationB. Demonstrate how to verbally de-escalate the situationC. Discuss the purpose of the medication with the clientD. Assess the need for physical restrains 29. A nurse is assessing a client who has a history of substance use disorder and states, “People are out to get me.” The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?A. CocaineB. AlcoholC. OpiumD. Heroin 30. A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply).A. BradycardiaB. LanugoC. DiarrheaD. Russell’s signE. Hypotension 31. A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?A. RisperidoneB. MethylphenidateC. ValproateD. Lithium 32. 33. A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?A. JaundiceB. BruisingC. Decreased libidoD. Urinary retention 34. A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?A. The client’s mother has asthmaB. The client’s father lives in the client’s homeC. The client is the oldest of their siblingsD. The client has several siblings 35. A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse’s priority?A. The client says he feels guilty about not spending more time with his partnerB. The client states that he is unable to eat more than once a dayC. The client frequently recalls negative experiences that occurred during his marriageD. The client relates that he is angry that the provider did not save his partner’s life 3637. A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has a major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? A. Significant weight lossB. Psychomotor retardationC. Markedly neglected hygieneD. Poor problem – solving skills 38. A nurse is providing counselling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify in the role of monopolizer?A. The adolescent son who refuses to share personal feelings.B. The adolescent daughter who attempts to dominate the discussionC. The father who intervenes whenever the siblings argue.D. The mother who expresses hostility toward the spouse. 39. A nurse is caring for a client who states, “I am too embarrassed to tell anyone what I did last night.” Which of the following responses should the nurse make?A. “Let’s discuss what you feel embarrassed about.”B. “Lots of people feel ashamed to tell their secrets.”C. “You shouldn’t feel embarrassed to talk to me.”D. “You will feel better if you tell me what you did last night.” 40. A nurse is performing an admission assessment for a client who was transferred from another mental health facility. The nurse suspects negligence. Which of the following actions should the nurse take?A. Write a detailed accusation against the previous facilityB. Notify the American Nurses Association of the occurrence.C. Document a factual account of the findings in the client’s medical recordD. Complete an incident report and include it in the client’s medical record. 41. 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. “I don’t feel anything but numbness anymore.”C. “it’ll be a long time before I’m happy again.”D. “I feel like I’m angry at the whole world right now.” 42. A nurse is assessing a client who has bipolar disorder and is taking lamotrigine. Which of the following findings is the nurse’s priority to report?A. ALT 20 units/LB. Platelets 200, 000/ mm3C. PhotosensitivityD. Skin rash 43. A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?A. Demonstrate a sympathetic attitude toward the client when providing care.B. Encourage the use of countertransference for the client.C. Provide consistent boundaries for the clientD. Maintain consistency in assigning health care staff for the client. 44. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates an accurate understanding of this medication’s effects?A. “I’ll take my medicine at bedtime because it will make me drowsy.”B. “This medicine will help me relax and feel less anxious.”C. “I know that I will be able to think more clearly now.”D. “I need to tell my doctor if I start gaining weight.” 45. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client’s refusal of medications?A. VeracityB. JusticeC. BeneficenceD. Autonomy 46. 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. Offer the client the medication at the next scheduled dose time.B. Implement consequences until the client takes the medication.C. Inform the client that he does not have the right to refuse the medication.D. Administrate the medication to the client via IM injection. 47. A nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss the client’s condition. Which of the following is the appropriate nursing action?A. Consult the clientB. Consult the client’s familyC. Contact the facility legal departmentD. Contact the provider 48. A nurse is assessing a client who has schizophrenia. which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply)A. Auditory hallucinationsB. Flight of ideasC. Decreased motivationD. Impaired memoryE. Delusions of grandeur 49. a nurse is assessing a client who recently experienced the loss of their partner. Which of the following s is the priority for the nurse to ask during this situational crisis?A. “Are you having thoughts about harming yourself?”B. “Who do you talk to when you need help?”C. “How do you think this event is affecting your life right now?”D. “What do you usually do to cope with problems in your life?” 50. 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 should the nurse plan to take next?A. Request a mental health consultation for the clientB. Provide a trained advocate to stay with the clientC. Offer prophylactic medication to prevent STIs.D. Conduct a pregnancy test. 51. A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?A. Ask the client to sign a no- suicide contract.B. Establish a rapport to foster trustC. Encourage the client to participate in group therapyD. Implement continuous one to one observation. 52. A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse’s station?A. A client who has schizophrenia personality disorderB. A client who has moderate- stage Alzheimer’s diseaseC. A client who has a history of dependent personality disorderD. A client who has a history of alcohol disorder. 53. A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?A. Request that the provider renew the prescription for restraints every 8 hr.B. Evaluate the client hourly while the restraints are applied.C. Obtain a prescription for restraints on as – needed basis.D. Have the provide assess the client within 1 hr after applying the restraints. 54. A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, “I feel unmotivated and don’t feel like leaving my home.” Which of the following recommendations should the nurse make to address the client’s social isolation?A. Write in a journal dailyB. Practice guided imagery each morningC. Join a low – impact exercise classD. Enroll in an online self-therapy course 55. A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol disorder. Which of the following recommendations should the nurse include in the plan?A. Refer the client to a self – help groupB. Teach the client to practice systematic desensitizationC. Contact a close relative of the client to discuss the discharge planD. Request a discharge prescription for buprenorphine for the client. 56. A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?A. A client who states she did not get a promotion because her boss dislikes herB. A client whose partner died 5 years ago still talks about him in the present tense.C. A client who states she will worry about her grades after she finishes planning a party.D. A client who has stomach pain before presenting a project to his coworkers. 57. A nurse in an in- patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?A. Encourage the client to watch television as distraction.B. Encourage the client to describe their feelings in a journalC. Administrate a dose of alprazolam to the clientD. Administrate a dose of atomoxetine to the client 58. A nurse is reviewing the medication administration record of a client who has major depressive and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?A. Calcium carbonateB. WarfarinC. FluoxetineD. Acetaminophen 59 60. A nurse in a long- term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?A. NeuropathyB. HypertensionC. WBC count 13, 000/ mm3D. BUN 16 mg/dl 61 62. A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? A. Reacting to the nurse as though she were his motherB. Talking negatively about other stuff membersC. Refusing to participate in group activitiesD. Expressing frustration regarding unit rules. 63. A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?A. Withhold the next dose of the medication.B. Apply hydrocortisone cream on the client’s rashC. Ask the client about a recent change in laundry detergentD. Explain that the medication causes a temporary rash. 64. A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? A. Ask the client’s family to encourage the client to receive ECT.B. Tell the client he cannot refuse the treatment because he was involuntarily committed.C. Inform the client that ECT does not require client consent.D. Document the client’s refusal of the treatment in the medical record. 65. A nurse is caring for client who has been taking valproic acid. Which of the following is an expected outcome of the medication?A. The client reports absence of auditory hallucinationsB. The client has decreased anxietyC. The client has decreased euphoric moodD. The client reports improved short – term memory 66. A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?A. The client expresses feelings of guilt.B. The client is unable to perform basic hygiene tasks.C. The client relocates from a house to an apartmentD. The client gives away some of the partner’s belongings. 67. A nurse is assessing a client who is restless and constantly mutters to himself. which of the findings should lead the nurse to suspect delirium?A. The client has a flat affectB. The client ‘s manifestations developed suddenlyC. The client’s speech is slow and repetitiousD. The client is unable to recognize objects. 68. A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory report should the nurse report to the provider?A. Platelet’s 100, 000/ mm3B. WBC count 8, 000/ mm3C. hemoglobin 16 g/dLD. RBC count 4.9 million/ mm3 69. A nurse is caring for a client who has depression following a recent job loss. Which of the following s should the nurse ask to assess the client’s personal coping skills?A. “Can you describe how you are currently feeling?”B. “How does this situation affect your life?”C. “Do you see yourself current situation affecting your future?”D. “How have you dealt with similar situations in the past?” 70. A nurse on an acute care unit is caring for a newly- admitted client who has anorexia nervosa. When the nurse prepares to obtain a morning weight, the client becomes agitated. Which of the following statement should the nurse make?A. “You don’t have to look at your current weight if you don’t want to.”B. “Why are you upset about us checking your weight today.”C. “we can check your weight tomorrow when you are feeling better.”D. “if you think you’ve gained too much weight, we can adjust your meal intake.Health ScienceScienceNursingNURS 2488Share
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1. A nurse is teaching about deep-breathing exerciseswith a client who reports experiencing intense stress at work. Which of the following
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