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    Exam Review

    1. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
      A)
      Hypotension and venous pooling in the extremities.
      B)
      Pain and a burning sensation upon urination and hematuria.
      C)
      Profuse diaphoresis and severe, pounding headache.
      D)
      Reports of chest pain and shortness of breath.
    2. A nurse is preparing to administer 1500 mL of IV fluid to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/h?
      Correct Answer:750 mL/h
    3. A nurse is caring for a client who was admitted with major depressive disorder. The nurse and client find that they have much in common, including each having a neighbor's son. They make plans to have dinner and a sleepover with their sons after the client is discharged. What does this situation reflect?
      A)
      A strong professional relationship.
      B)
      Countertransference.
      C)
      Successful relationship building.
      D)
      Boundary blurring.
    4. A nurse is teaching a client who has a fear of heights about the use of systematic desensitization as a method of behavioral therapy. Which of the following client statements indicates an understanding of the teaching?
      A)
      "I will be asked to imitate my therapist's actions around heights."
      B)
      "I will snap a rubber band on my wrist when heights scare me."
      C)
      "I will need to stand on a very high place until I am calm."
      D)
      "I will slowly be exposed to places of increasing height."
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    Exam Review

    1. A client newly placed on an involuntary hold is being given an orientation to the psychiatric unit. The nurse includes information about the client's rights. Which of the following statements should the nurse include? Select all that apply.
      (SATA)
      A)
      "You have the right to refuse prescribed treatment."
      B)
      "You have the right to mail out letters."
      C)
      "You have the right to file grievances against staff."
      D)
      "You have the right to a private room."
      E)
      "You have the right to conduct religious practices."
    2. A nurse is administering oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform?
      A)
      Refer the case to the facility's ethics committee.
      B)
      Document the client's refusal of the medication in the medical record.
      C)
      Administer the medication by another route.
      D)
      Inform the client that due to her involuntary admission, she cannot refuse a sedative.
    3. A charge nurse is discussing examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select the 3 that apply.)
      (SATA)
      A)
      To assess cognitive ability, ask the client to write a sentence.
      B)
      To assess mood, observe facial expression.
      C)
      To assess cognitive ability, ask the client to count backward by sevens.
      D)
      To assess appearance, take note of the client's nutritional status.
      E)
      To assess recent memory, have the client repeat a list of objects.
      F)
      To assess the client's abstract thinking, ask the client to identify our most recent presidents.
    4. A very anxious client is hesitant to start a new medication and asks the nurse for guidance. The nurse responds, "I'm happy to review the side effects with you and discuss the pros and cons. This may help you make an informed decision, and I support you." In this scenario, the nurse is upholding the client's:
      A)
      Autonomy
      B)
      Beneficence
      C)
      Fidelity
      D)
      Veracity
    Page 2 of 4

    Exam Review

    1. A nurse is preparing to administer diazepam 4 mg IV bolus stat. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)
      Correct Answer:0.8 mL
    2. A nurse is caring for a client who was admitted to the mental health unit for treatment. The client states, "I am a nurse on the medical-surgical unit, and I don't want my coworkers to know." Which of the following actions should the nurse take?
      A)
      Explain to the client that there is a legal obligation to share information.
      B)
      Advise the client that her supervisor will be informed.
      C)
      Tell the client her coworkers' opinions should not matter.
      D)
      Inform the client that the information will be shared with the treatment team.
    3. A community mental health nurse is addressing substance use by adolescents. Which of the following interventions should the nurse include as a method of primary prevention?
      A)
      Encourage random drug screening of adolescents participating in extracurricular activities.
      B)
      Offer substance use treatment programs for adolescents from low-income households.
      C)
      Provide a presentation to local schools on resisting peer pressure for substance use.
      D)
      Educate high school teachers about detecting the manifestations of substance use.
    4. A nurse performed these actions while caring for patients in an inpatient psychiatric unit. Which action violated patients' rights?
      A)
      Told a patient he can't wear his steel-tipped boots in the facility.
      B)
      Told a patient he can't call his family because he's calmed down too much.
      C)
      Told a patient he can't save his scheduled medication for later.
      D)
      Inspected a food basket addressed to a patient before giving it to the patient.
    Page 3 of 4

    Exam Review

    1. The psychiatric nurse works towards providing a therapeutic milieu for clients. What is the primary purpose of managing the milieu on a psychiatric unit?
      A)
      To provide a show of force that would deter clients from breaking unit rules.
      B)
      To foster stronger social relationships between clients and staff.
      C)
      To synergize with the autocratic leadership style of inpatient therapy.
      D)
      To assist all the clients in meeting their treatment goals.
    2. A nurse is caring for a client who is receiving cognitive behavioral therapy. The client tells the nurse, "Nothing good ever came from my marriage." To best support cognitive reframing, which of the following responses should the nurse offer?
      A)
      "What were the bad things that came from your marriage?"
      B)
      "What did you learn from your marriage to help you in the future?"
      C)
      "Did you have any romantic relationships prior to your marriage?"
      D)
      "Only you can understand how your marriage has negatively affected you."
    3. A nurse in an acute mental health facility is leading a nursing education session about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include?
      A)
      A client who is involuntarily admitted must take prescribed medications.
      B)
      An involuntary admission is justified if the client is a danger to themselves or others.
      C)
      An involuntary admission of a client is limited to two weeks.
      D)
      A client who is involuntarily admitted can leave the facility against medical advice.
    4. A nurse delegates a licensed practical nurse (LPN) to perform suicide precautions. Which of the following actions by the LPN indicates to the nurse that they require further education?
      A)
      Remaining with the client while family members visit.
      B)
      Asking the nurse at lunchtime to assign another LPN for this task until their return.
      C)
      Ambulating the client's roommate while the client is on suicide precautions.
      D)
      Accompanying the client to physical and occupational therapy.
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