Exam Review

A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum and the nurse suspects abuse.Which of the following actions should the nurse take?
A)
Interview the child about the suspected abuse with a parent present.
B)
Complete an incident report for risk management.
C)
Inform the parents that the findings must be reported to authorities.
D)
Report the suspected abuse to the appropriate child protective services agency.
A nurse is contributing to the plan of care for a client who has acute delirium.Which of the following interventions should the nurse include in the plan of care?
A)
Keep the client's room dark at night.
B)
Limit the client's need to make decisions.
C)
Discourage visitation from the client's family.
D)
Provide a consistent daily routine.
A nurse is reinforcing teaching with a client who has schizophrenia.The nurse should identify which of the following manifestations as an indication of relapse?
A)
Increased sleep.
B)
Obsession with hygiene rituals.
C)
Excessive appetite.
D)
Increased suspiciousness.
A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night.Which of the following recommendations should the nurse make?
A)
"Drink 5 ounces of red wine roughly 30 minutes before bed.”.
B)
"Stay in bed for 1 hour before getting up if you are unable to sleep.”.
C)
"Exercise 1 hour before bedtime.”.
D)
"Limit caffeine to one or two servings during daytime hours.”.

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Exam Review

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?
A)
Liver enzymes.
B)
Sodium level.
C)
Uric acid.
D)
Erythrocyte sedimentation rate.
A nurse is caring for a group of older adult clients who receive home care.Which of the following clients should the nurse interview about the possibility of caregiver abuse or neglect?
A)
A client who has a bruise on their shin.
B)
A client who is 9 kg (20 lb) over their recommended weight.
C)
A client whose caregiver pays the client's bills.
D)
A client who is wearing soiled clothing.
A nurse is reinforcing teaching with a client who has chronic stress.Which of the following instructions should the nurse provide?
(SATA)
A)
Engage in regular physical activity.
B)
Consume a moderate amount of caffeine.
C)
Limit exercise close to bedtime.
D)
Aim for approximately 7-9 hours of sleep per night.
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
A)
"Tell me more about your relationship with your partner.”.
B)
"Grief affects everyone differently; your feelings are valid.”.
C)
"It's important to stay busy to take your mind off things.”.
D)
"Have you considered joining a support group for bereavement?"

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Exam Review

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide.Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)
(SATA)
A)
Access to firearms in the home.
B)
Sibling history of suicide.
C)
Being currently unmarried.
D)
Expressing feelings of hopelessness.
E)
A recent significant loss.
A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt.Which of the following behaviors indicates that the contract has been effective?
A)
The client seeks out a staff member when experiencing urges to self-harm.
B)
The client spends time alone in their room to manage overwhelming feelings.
C)
The client avoids discussing their difficult emotions with the treatment team.
D)
The client attempts to suppress feelings of anger and frustration.
A nurse is contributing to the plan of care for a client who has borderline personality disorder.Which of the following interventions should the nurse recommend?
A)
Encourage the client to communicate with staff when feeling urges for self-harm.
B)
Assist the client in developing healthy coping mechanisms for intense emotions.
C)
Advise the client to avoid expressing their feelings assertively.
D)
Offer the client additional attention only when self-mutilating behaviors occur.
A nurse is assisting in the care of a client following a mastectomy.Which of the following responses by the client indicates acceptance of their altered body image?
A)
"I am starting to feel more comfortable looking at myself in the mirror.”.
B)
"I am worried about how my partner will perceive my appearance now.”.
C)
"I prefer to wear loose-fitting clothing to conceal the changes.”.
D)
"I am focused on my recovery and adapting to these changes.”.

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Exam Review

A nurse is caring for a male client who is to begin therapy with valproic acid.Which of the following diagnostic results should the nurse plan to review before administering the first dose?
A)
Liver function tests.
B)
Chest x-ray.
C)
Prostate-specific antigen test.
D)
Urine culture.
A nurse is reviewing the treatment plan of a client who is receiving anger management therapy.Which of the following Questions should the nurse ask the client to evaluate the effectiveness of the treatment plan?
A)
"Do you feel like your anger is becoming more manageable?".
B)
"What do you do when something makes you angry?".
C)
"Did you learn any coping strategies from your counselor?".
D)
"Have you been attending your anger management group?".
A nurse is preparing to administer fluphenazine 7.5 mg PO daily to a client who has schizophrenia. Available is fluphenazine elixir 2.5 mg/5 mL. How many mL should the nurse administer?
A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy.The nurse should notify the provider for which of the following findings?
A)
Asthma.
B)
Crohn's disease.
C)
Renal colic.
D)
Cardiac arrhythmia.

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Exam Review

A nurse is caring for multiple clients on a mental health unit.Which of the following clients should the nurse attend to first?
A)
A client who is repeatedly approaching the nurses' station to request medication for their anxiety.
B)
A client who is standing in their room, yelling obscenities, and throwing their clothes.
C)
A client who has bipolar disorder and is continuously pacing at the end of the hall.
D)
A client in the dayroom who is screaming at other clients about what is on the television.
A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?
A)
Demonstrate a neutral demeanor.
B)
Use an overly friendly approach.
C)
Ask the client why he is suspicious of others.
A nurse is caring for a client who has an opioid use disorder.The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
A)
Diazepam.
B)
Phenobarbital.
C)
Buprenorphine.
D)
Chlordiazepoxide.
A nurse is caring for a client who is experiencing a situational crisis.Which of the following actions should the nurse take first?
A)
Assist with a client referral for social services.
B)
Identify if the client has thoughts of self-harm.
C)
Reinforce teaching on the client's use of coping skills.
D)
Encourage the client to use personal support systems.

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Exam Review

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.The caregiver reports that the client awakens at night and wanders.Which of the following strategies should the nurse suggest?
A)
Place a lock at the top of doors leading outside.
B)
Administer an antianxiety medication before bedtime.
C)
Encourage the client to nap during the day.
D)
Use light restraints while the client is in bed.
A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.The client has prescriptions for an anxiolytic and an SSRI antidepressant.Which of the following precautions should the nurse take?
A)
Implement 24-hr one-to-one nursing observation.
B)
Document the client's behavior every 2 hr.
C)
Restrict interactions with other clients.
D)
Administer prescribed medication via the IM route.
A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?
A)
"Tell me about your baby. Where is she now?"
B)
"Do you have a friend who could help you?"
C)
"Having a newborn must be stressful. Do you have other children?"
D)
"Have you discussed this with your partner?"
A nurse is collecting data from an adult client in an outpatient mental health clinic.The nurse should identify which of the following events as a potential cause of a maturational crisis?
A)
Motor-vehicle crash
B)
Loss of job
C)
A child leaving for college
D)
Divorce

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