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    Exam Review

    1. A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
      (SATA)
      A)
      Place the client in a reclining chair.
      B)
      Encourage physical activity prior to bedtime.
      C)
      Install sensor devices on outside doors.
      D)
      Put locks at top of doors.
      E)
      Position the mattress on the floor.
    2. A nurse is assessing a client who has a new diagnosis of alcohol use disorder. Which of the following client statements should the nurse expect if the client is in denial about their diagnosis?
      A)
      "I have been drinking for years. It's affected me in a lot of ways."
      B)
      "I can quit drinking at any time. I don't need anyone's help."
      C)
      "I don't think decreasing the number of drinks I have each day will help."
      D)
      "I am tired of letting my family and friends down."
    3. A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following medications should the nurse prepare to administer?
      A)
      Methadone
      B)
      Disulfiram
      C)
      Lorazepam
      D)
      Naltrexone
    4. A nurse in a mental health facility is planning a training program for new staff members on managing aggressive clients. Which of the following instructions should the nurse plan to include?
      A)
      Recruit other staff members to talk the client down.
      B)
      Offer the client a PRN medication to reduce their anxiety.
      C)
      Attempt to calm the client with therapeutic touch.
      D)
      Assume authority by standing directly in front of the client.
    Page 1 of 13

    Exam Review

    1. A nurse is conducting chart audits for a mental health facility. Which of the following findings should the nurse identify as requiring completion of an incident report?
      A)
      A client tells the nurse exact details about their suicide plan.
      B)
      A client who has mania refuses to stop pacing the dayroom despite limit setting on the behavior.
      C)
      A client did not receive their antipsychotic medication yesterday.
      D)
      A client who has major depressive disorder refuses to leave their room.
    2. A nurse is caring for a school-age child who has autism spectrum disorder and has difficulty expressing emotions. Which of the following interventions should the nurse include in the child's plan of care?
      A)
      Provide extended play sessions for the child with other children.
      B)
      Teach the child guided imagery.
      C)
      Use progressive muscle relaxation exercises with the child.
      D)
      Implement music therapy for the child.
    3. A nurse is preparing a client who is scheduled for electroconvulsive therapy. The client states, "I want to cancel my procedure and think it over." Which of the following actions should the nurse take?
      A)
      State the pros and cons of having the procedure.
      B)
      Tell the client it is too late to cancel the procedure.
      C)
      Inform the client that they will notify the provider.
      D)
      Contact the next of kin for permission to proceed with the procedure.
    4. A nurse in an emergency department is assessing a client who verbalized to a family member that they do not want to live anymore after the death of their child. Which of the following assessments should the nurse plan to perform first?
      A)
      Ask the client if they have a trusted person they can talk with.
      B)
      Ask the client if they have attempted to hurt themselves in the past.
      C)
      Ask the client about their past psychosocial medical history.
      D)
      Ask the client if they have a plan for ending their life.
    Page 2 of 13

    Exam Review

    1. A nurse is caring for a client who is recovering from substance use disorder and is preparing to be discharged. Which of the following factors should the nurse identify as a potential barrier to recovery?
      A)
      Downloaded a new app to monitor for relapse cues
      B)
      Plans to move into a halfway house with residential treatment
      C)
      Will stay with a codependent family member for a few weeks
      D)
      Identifies potential triggers that may cause relapse
    2. A nurse is speaking to a former high school friend. The friend states, "I heard one of our high school teachers was admitted to your hospital. Is everything okay?" Which of the following responses should the nurse make?
      A)
      "I cannot discuss the care of anyone who might be hospitalized in our facility."
      B)
      "I recommend you contact the hospital to see if she has been admitted."
      C)
      "I can only discuss the status of a client with the client's family."
      D)
      "I think that you should contact the high school for information about her."
    3. A nurse is planning care for multiple clients who each have a diagnosis of schizophrenia. Which of the following clients should the nurse plan to see first?
      A)
      A client who is experiencing new onset catatonia
      B)
      A client who is experiencing akathisia
      C)
      A client who is experiencing new onset echolalia
      D)
      A client who is experiencing command hallucinations
    4. A nurse has received change-of-shift report for four clients. Which of the following findings should the nurse report to the provider immediately?
      A)
      A client who has depressive disorder and reports loss of energy
      B)
      A client who takes lithium and has a decreased urinary output
      C)
      A client who takes an antipsychotic and has gained 0.91 kg (2 lb) in 2 weeks
      D)
      A client who has dementia and has difficulty recognizing objects
    Page 3 of 13

    Exam Review

    1. A nurse is teaching a client who has posttraumatic stress disorder about using mindfulness to manage stress. Which of the following statements by the client indicates an understanding of the teaching?
      A)
      "I will focus on pleasant images to distract myself from feeling stressed."
      B)
      "I will progressively relax my muscles from my face to my toes."
      C)
      "I will concentrate on what I am seeing, feeling, and hearing in the moment."
      D)
      "I will use my smartwatch to track my sleep patterns and heart rate."
    2. A nurse is building a therapeutic relationship with a client who has an eating disorder. Which of the following activities should the nurse initiate during the relationship's orientation phase?
      A)
      Using memories to validate the relationship experience
      B)
      Mutually deciding and agreeing on the goals of the relationship
      C)
      Teaching and encouraging the use of problem-solving skills
      D)
      Discussing the incorporation of new strategies into daily life
    3. A nurse is caring for a client who has avoidant personality disorder. Which of the following therapeutic interventions should the nurse include in the client's plan of care?
      A)
      Thought stopping
      B)
      Assertiveness training
      C)
      Systematic desensitization
      D)
      Dialectical behavior therapy
    4. A nurse is assessing a client who takes citalopram to treat depression. Which of the following findings should the nurse identify as an indication of serotonin syndrome?
      A)
      Constipation
      B)
      Muscle flaccidity
      C)
      Lethargy
      D)
      Tremors
    Page 4 of 13

    Exam Review

    1. A nurse is assessing a client who has mania. Which of the following manifestations is the priority for the nurse to report to the provider?
      A)
      Pressured speech
      B)
      Impaired problem-solving
      C)
      Increased self-confidence
      D)
      Constant activity
    2. A nurse is conducting a home visit with a client who is diagnosed with bipolar I disorder. Which of the following statements should the nurse identify as an example of disturbed thought process?
      A)
      "I just don't feel like talking about myself or my illness today."
      B)
      "It is up to me to take care of myself."
      C)
      "I sleep a lot during the day, so daytime visits are hard for me."
      D)
      "My home is my castle, and you are trespassing."
    3. A nurse in the emergency department is caring for a client who has serotonin syndrome. The nurse should assess the client for which of the following manifestations?
      A)
      Bradycardia
      B)
      Priapism
      C)
      Hyperpyrexia
      D)
      Paresthesia
    4. A nurse is planning care for a client who has experienced partner violence. The nurse should identify which of the following outcomes as the priority?
      A)
      The client identifies support systems.
      B)
      The client identifies techniques to reduce their stress.
      C)
      The client joins a group.
      D)
      The client develops a safety plan.
    Page 5 of 13

    Exam Review

    1. A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings should be the nurse's priority?
      A)
      Having difficulty concentrating
      B)
      Decreased fluid intake
      C)
      Demonstrating impulsive behaviors
      D)
      Sleeping for 3 hours a night
    2. A nurse is caring for a client who has been taking lithium mg PO daily. Which of the following client statements requires follow-up by the nurse?
      A)
      "I will not take over-the-counter medicines without checking with my prescriber."
      B)
      "I have been eating a lot of potato chips, pretzels, and salted nuts lately."
      C)
      "I will get bloodwork drawn every 3 months."
      D)
      "I will always drink at least six 12-ounce glasses of water a day."
    3. A nurse is caring for a client who takes lithium for bipolar disorder and has a lithium level of 2.3 mEq/L. Which of the following findings should the nurse expect to observe?
      A)
      Gastrointestinal upset
      B)
      Severe hypertension
      C)
      Fine hand tremors
      D)
      Large output of dilute urine
    4. A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity?
      A)
      Sodium 130 mEq/L (136 to 145 mEq/L)
      B)
      Calcium 8.6 mg/dL (9 to 10.5 mg/dL)
      C)
      Chloride 108 mEq/L (98 to 106 mEq/L)
      D)
      Potassium 5.2 mEq/L (3.5 to 5 mEq/L)
    Page 6 of 13