Exam Review

A nurse in an acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium. The client has been living independently at home. Which of the following statements by the adult child demonstrates the teaching has been effective?
A)
"I should look into the possibility of long-term care for my father when he is discharged."
B)
"I would like information about respite care for when my father is discharged."
C)
"I expect that my father will no longer be confused when he is discharged."
D)
"I will obtain a permanent identification bracelet for my father when he is discharged."

A nurse on a mental health unit is caring for a client. For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

	Anticipated	Contraindicated
Encourage the client to take rest periods throughout the day	✓
Weigh the client daily	✓
Increase the client's environmental stimuli		✓
Offer the client finger foods	✓
Apply restraints to the client		✓

A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect?
A)
Lanugo
B)
Dental caries
C)
Cold extremities
D)
Amenorrhea
A nurse is caring for a client whose partner died 3 years ago. The client has withdrawn socially and has not participated in regular activities since the funeral. The nurse should identify that the client is experiencing which of the following types of grief?
A)
Anticipatory grief
B)
Exaggerated grief
C)
Chronic grief
D)
Disenfranchised grief

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Exam Review

A nurse is caring for a client who has bipolar disorder. The nurse is planning care for the client. Select the 4 interventions the nurse should include in the client’s care.
(SATA)
A)
Sit with the client during mealtimes.
B)
Turn on the television for the client to watch.
C)
Remove sharp objects from the client’s room.
D)
Observe the client every 15 min.
E)
Provide the client with a low-protein diet.
F)
Offer the client physical activities.
G)
Offer the client physical activities.
A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatments. One of the adult children is angry with the provider and blames the provider for their parent's death. Which of the following defense mechanisms is the family member using?
A)
Dissociation
B)
Rationalization
C)
Repression
D)
Displacement

A nurse in an outpatient clinic is caring for a client.

	Anticipated	Not Indicated
Positron emission tomography (PET) scan of the head	✓
Physical examination	✓
Administer the Mini Mental State Examination (MMSE)	✓
Review all prescribed and over-the-counter medications	✓
Admit the client to an inpatient behavioral health unit		✓

A nurse is creating a plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
A)
Allow the client to eat in their room for the first week.
B)
Obtain the client’s vital signs once each day.
C)
Weigh the client daily after first voiding.
D)
Allow the client to determine their daily calorie intake.

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Exam Review

A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?
A)
A residential rehabilitation program
B)
Intensive outpatient therapy
C)
Alcoholics Anonymous
D)
A halfway house
A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?
A)
"You should ask your provider that question."
B)
"I wouldn't worry about any permanent damage you might have caused right now."
C)
"Why do you feel like you have damaged your body?"
D)
"You're afraid you have caused physical injury to yourself?"
A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?
A)
The client slept 4 hr last night.
B)
The client refuses to take a shower.
C)
The client ate half of the provided snack.
D)
The client refuses to drink fluids.
A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?
A)
"This therapy will help me use specific body postures to achieve balance."
B)
"This therapy will improve my range of motion."
C)
"This therapy will help me to concentrate on soothing images."
D)
"This therapy will help me recognize changes in my blood pressure."

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Exam Review

A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include?
A)
"A client loses the right to refuse prescribed medications when they are admitted involuntarily."
B)
"Clients admitted involuntarily are considered to be incompetent to provide informed consent."
C)
"A provider can write a prescription for restraints to use on a client on an as-needed basis."
D)
"If a client threatens to seriously harm someone, the provider should notify that person of the threat."
A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?
A)
"You should ask your provider that question."
B)
"I wouldn't worry about any permanent damage you might have caused right now."
C)
"Why do you feel like you have damaged your body?"
D)
"You're afraid you have caused physical injury to yourself?"
A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?
A)
The client slept 4 hr last night.
B)
The client refuses to take a shower.
C)
The client ate half of the provided snack.
D)
The client refuses to drink fluids.
A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?
A)
"This therapy will help me use specific body postures to achieve balance."
B)
"This therapy will improve my range of motion."
C)
"This therapy will help me to concentrate on soothing images."
D)
"This therapy will help me recognize changes in my blood pressure."

Page 4 of 12

Exam Review

A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include?
A)
"A client loses the right to refuse prescribed medications when they are admitted involuntarily."
B)
"Clients admitted involuntarily are considered to be incompetent to provide informed consent."
C)
"A provider can write a prescription for restraints to use on a client on an as-needed basis."
D)
"If a client threatens to seriously harm someone, the provider should notify that person of the threat."
A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?
A)
Check on the client every 30 min while they are in their room.
B)
Request that a family member bring personal hygiene items from home.
C)
Provide the client with plastic eating utensils.
D)
Keep the client’s door closed at night.
A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
A)
Selective inattention
B)
Urinary frequency
C)
Sharpened perceptions
D)
Voice tremors
A nurse is providing dietary teaching to a client who has a prescription for tranylcypromine. The nurse should instruct the client to avoid which of the following foods while taking this medication?
A)
Fresh salmon
B)
Aged cheese
C)
Smoked meats
D)
Red wine

Page 5 of 12

Exam Review

A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include?
A)
Record the client’s behavior every 15 min while in restraints.
B)
Secure the restraint to the client’s bed rail using a slip knot.
C)
Raising all four bedrails to keep a client in bed is not considered a restraint.
D)
The nurse should assess a restrained client once every 2 hr.
A nurse is caring for a client who appears extremely agitated and believes that pacing the floor a specific number of times is necessary or “something terrible” will happen. Which of the following responses should the nurse make?
A)
"Nothing terrible is going to happen to you. You must stop this behavior."
B)
"It must be hard for you to have to pace the floor. Let’s talk about your feelings."
C)
"Are you looking for sympathy? There are other ways to get attention."
D)
"I understand your need to work off excess energy. Are you angry about something?"
A home health nurse is caring for a new client who has hoarding disorder that involves food. Which of the following actions should the nurse take first?
A)
Encourage the client to verbalize their feelings about hoarding.
B)
Refer the client to a support group for hoarding disorder.
C)
Discuss the health risks associated with hoarding of food.
D)
Assist the client with completing the Hoarding Scale Self-Report.
A nurse is caring for a client following a fire that destroyed their home and killed one of their children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first?
A)
"How are you feeling at this time?"
B)
"Is there someone I can call to be with you now?"
C)
"Can you tell me what you have done in the past when going through a difficult time?"
D)
"Have you thought of harming yourself?"

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