Exam Review

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:
A)
There are any signs of infection.
B)
There is a decrease in hallucinations.
C)
Appetite continues to decrease after one week.
D)
Insomnia occurs for more than two nights.
A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?
A)
Your mother seems like an understanding person. I’ll help you approach her.
B)
It’s quite common for clients to feel that way after a lengthy hospitalization.
C)
Why don’t you talk to your mother? You may find out she doesn’t feel that way.
D)
You feel that your mother does not want you to come back home.
A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?
A)
I may consider dating you once you have fully recovered.
B)
It’s against hospital policy for me to date clients.
C)
This is a professional relationship, and we need to be clear on that.
D)
I’m sorry, but I’m married and not interested in dating.
Upon assessment of the lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:
A)
Wheezes
B)
Rhonchi
C)
Fine crackles
D)
Vesicular sounds

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Exam Review

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:
A)
Encourage social interaction.
B)
Discuss the bizarre behavior.
C)
Give the client information about her illness.
D)
Provide a safe environment.
A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.
Correct Answer:600 mL/hr
A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?
A)
“You should share this thought with your psychiatrist.”
B)
“I can make that promise to you based on nurse-client privilege.”
C)
“Those kinds of thoughts will make your hospitalization longer.”
D)
“I cannot promise that. Confidentiality does not include plans to hurt others.”
A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?
A)
Ask the client direct questions about the hallucinations.
B)
Act as if the hallucinations are real.
C)
Instruct the client to argue with the voices.
D)
Explain to the client that the hallucinations will subside soon.

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Exam Review

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:
A)
manifestation of dyslexia.
B)
example of loose associations.
C)
neologism.
D)
flight of ideas.
A patient is prescribed morphine sulfate 5 mg IV every 4 hours as needed for a pain level greater than 7 on a scale of 0-10. Morphine is available in 8 mg/mL vials. How many mL will the nurse give for the correct dose? Round to the nearest hundredth. Use a preceding zero if necessary. Do not use trailing zeros.
Correct Answer:0.63 mL
An inpatient on the psychiatric unit is having a panic attack. An appropriate nursing intervention at this time would be to:
A)
Increase external stimuli.
B)
Stay with the client and speak to them in a calm manner.
C)
Allow the client to have their requested space.
D)
Review the updated problem list with the client.
A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?
A)
Administer the medication with food.
B)
Administer the medication to the client at night to avoid daytime sedation.
C)
Encourage the client to avoid drinking alcohol when taking this medication.
D)
Assess for history of smoking.

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Exam Review

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?
A)
Hypertension
B)
Tinnitus
C)
Metallic taste
D)
Dizziness
A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?
A)
Confirming boundaries by setting limits on behavior.
B)
Providing reality orientation.
C)
Providing client education in a direct manner.
D)
Ensuring physical need fulfillment.
The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?
A)
Word salad.
B)
Loose association.
C)
Clang association.
D)
Ideas of reference.
A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?
A)
The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.
B)
The client diagnosed with a somatoform disorder can be easily cured with medication.
C)
The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.
D)
The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.

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Exam Review

Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?
A)
Ask open-ended questions.
B)
Focus on what is happening in the here and now.
C)
Assume knowledge of what is meant when the client talks about “they.”
D)
Limit contact to one or two short interactions daily.
The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:
A)
The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.
B)
Previous experiences, the availability of medication, and the desire to cope.
C)
Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.
D)
The time of day, the client’s mood, and the availability of escape from the situation.
As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?
A)
“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”
B)
“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”
C)
“You’ve had a month to come up with a plan to work on your well-being.”
D)
“Hopefully you learned from being in counseling. I’m sure this will work out fine.”
A patient with mild Alzheimer’s disease is prescribed to take galantamine. Which statement best describes how this medication works to treat this disease?
A)
Prevents the breakdown of acetylcholine.
B)
Decreases amyloid plaques in the brain.
C)
Increases acetylcholine levels in the brain.
D)
Limits neurotransmitter engagement of NMDA receptors

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Exam Review

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?
A)
Uses relaxation techniques for stress reduction.
B)
Expresses an interest in yoga to improve flexibility.
C)
Has tried acupressure for pain relief several years ago.
D)
Has been using herbal supplements without consulting a healthcare provider.
The nurse is attempting to de-escalate a client who is becoming increasingly agitated on the unit. Which of the following interventions would be appropriate for this type of client? (SELECT ALL THAT APPLY)
A)
Use a calm voice.
B)
Speak louder than the client so as to be heard.
C)
Reduce stimuli for the client.
D)
Attempt to redirect the client.
E)
Reprimand the client for upsetting everyone.
A nurse is caring for a client who has schizophrenia. The client is in the dayroom and shouting at other clients, stating, “Do not eat the food here. The staff is poisoning the food!” The nurse should document that the client is experiencing which type of delusion?
A)
Somatic
B)
Persecutory
C)
Erotomanic
D)
Grandiose
A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.
A)
Slowed psychomotor activity
B)
Impaired attention and concentration
C)
Hallucinations and delusions
D)
Decreased alertness or responsiveness
E)
Agitation and restlessness

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