A nurse is documenting admission assessment findings for a client who has major depressive disorder

The client reports an inability to breathe easily

Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated with clozapine. When using the greatest risk framework, the nurse should identify that the greatest risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to the provider.

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Terms in this set (120)

A nurse is admitting and adolescent client who has anorexia nervosa. Which of the following clinical findings should the The nurse expect?

Amenorrhea

Nurses caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory value should the nurse expect?

Increased CPK creatine Phosphokinase

While observing group therapy and nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder her. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make every day decisions

I need to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include?

Exhibits a realistic self-concept

Educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following characteristics of this disorder should the nurse include in the teaching?

Language delay

A nurse is admitting a client who has depression to an inpatient mental health facility. The client states that he feel so bad that he is certain he will never be discharged. Which of the following is an appropriate response?

You seem concerned about getting out of the hospital

A nurses is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self directed injury or injuring others?

Command hallucinations

Understanding communicating with the client in an inpatient mental health facility . which of the following demonstrate's the use of active listening ?

Attention to body language

Nurse is providing teaching to a client who has a new prescription of haloperidol. Which of the following side should the nurse instruct the client to report to the provider?

Shuffling gait

Nurse is caring for a client who has anorexia nervosa. Which of the following criteria required hospitalization?

Temperature of 35.6 Celsius or 96.1 Fahrenheit

Trying to discharge an older adult client, who attempted suicide, to his home where he lives alone. The client also has difficulty performing ADLs. Which of the following referral's should the nurse initiate?

Occupational therapy,

meal delivery services,

physical therapy,

home health services

A nurse is caring for a client who has schizophrenia and is threatening to harm others on the unit the provider prescribes haloperidol and seclusion. Which of the following should be included in the plan of care?

Offer the client food every hour monitor behavior every 15 to 30 minutes

A nurse in a mental health facility observed the client was experiencing panic level of anxiety. Which of the following actions should the nurse take first?

Accompany the client to a quiet room

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

Early identification of changes such as decrease in social involvement is important

Admitting a client to an inpatient unit who is in the acute stage schizophrenia. The nurse observes the following findings; restlessness, pacing with clenched fist, Eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate?

Stay with the client in a quiet setting

A nurse is assessing a client in the emergency department. The client appeared agitated, his blood pressure is 152/90 for his heart rate is 110 for a minute and his pupils are dilated.

The nurse should suspect intoxication with which of the following substances

Cocaine

Caring for a client receiving imipramine for depression. For which of the following adverse affects should the nurse monitor?

Urinary retention

A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the following assessment finding indicates that the client is experiencing extrapyramidal adverse affects?

Lipsmacking and tongue rolling

diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg per mill how many mls the nurse and administer round the answer to the nearest 10th using a little zero if possible

1.5 ML's

The nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with posttraumatic stress disorder PTSD

Distressing dreams

Difficulty concentrating

Exaggerated startle response

A nurse is developing a discharge plan for client who has a history of gambling dependency and includes participation in a support group. The nurse should tell the client that which of the following is the purpose of attending a support group

Provide assurance that others have a similar problem

A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium?

Sudden onset

The nurse is caring for a client whose child recently died in a motor vehicle crash and states " I just want to join him." Which of the following is the nurses priority response

Are you thinking about harming yourself

Caring for a client who is scheduled to undergo ECT. The provider has explained the procedure to the client which of the following statements made by the client indicates a need for further teaching

This procedure can increase my risk for developing Parkinson's disease

The nurse is meeting with a client being discharged from a substance use disorder treatment program. Which of the following client statement indicates that client is planning to make a lifestyle change?

I will change my route going home from work so I don't pass my favorite bar

A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse "that man in my room never sleeps and he keeps me up "Which of the following is an appropriate intervention for the nurse to take?

Move the client who has bipolar disorder to a private room

The potential adverse effects of lithium with a client who began the medication two weeks ago. Which of the following should the nurse instruct the client to monitor and report?

Coarse hand tremor

A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family members seems distracted. Which of the following is an appropriate action by the nurse?

Ask the family member if she has any thoughts or questions about this portion of the treatment plan

Client has schizophrenia is prescribed risperidone. Which of the fine laboratory tests should the nurse monitor?

Blood glucose

A nurse in the providers office is talking with a client who has diabetes mellitus and in HB A1 C of 8.5%. The client states that she is under a lot of stress and that she doesn't want to talk about her diabetes mellitus right now. Based on his comments the nurse should know that the client is demonstrating which the following defense mechanism

Suppression

Nurse is conducting a counseling session with the client has depression. Which of the fine statements by the client indicates the client is demonstrating transference?

I feel like you talk to me like my sister does

A nurse is assessing a client who has schizophrenia. Which the following findings identify as a negative symptoms of this disorder?

Flat affect.

Assessing a client in the emergency department who is brought in by a caregiver. Caregiver states the client fell recently. The nurse observes bruises on the clients abdomen, back, and legs and suspects abuse. Which of the following actions should the nurse take first?

Check the client for other signs and symptoms of abuse

Client has borderline personality disorder. Which of the following is a part of the planning care for this client?

The client will refrain from self mutilation

A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The clients morning lithium level is 1.5. Which of the following additional laboratory data has the highest priority?

Serum sodium 125 mEq

A nurses caring for a client receiving tranyclpromine which of the following is an appropriate menu choice for the nurse to suggest

Roasted chicken

During morning rounds a nurse find a client who has schizophrenia trembling and tearful in her bed. The client reports that A family member placed a bomb in her room during visiting hours. Which of the following is an appropriate action by the nurse?

Assess the client for evidence of a perceptual disturbance

Trying to admit four clients in an inpatient mental health facility which the following client's can give informed consent

A 35-year-old who has major depressive disorder

A nurse is facilitating a support group and observes that one member remain silent, even after attending several sessions. Which of the fine strategies should the nurse use to encourage the members participation?

Divide the group into Pairs to discuss the topic, then summarize the discussion to the group

Performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse which of the following statement indicates the greatest potential risk factor for abuse?

My son enjoys a couple of drinks each night to unwind

Interviewing an older adult client in an outpatient mental health clinic. Which of the following strategies should the nurse use?

Conduct the interview in a private area

A nurse in an outpatient clinic is assessing a student says he feels restless and irritable before taking an exam the nurses knows that the clinical findings as which of the following?

Mild anxiety

A nurse is obtaining a health history during a clients admission to a mental help facility. The client begins to talk on her cell phone. When the client finishes talking, she reports the nurse "that was the president I leave in the morning on my new mission" which of the following is an appropriate response

How long have you been having conversations with the president

A nurse is caring for a client in a mental health facility who has recently started a new prescription for volporic acid. Which of the following should the nurse monitor to determine effectiveness of this medication

The client has decreased episode of pressured speech

A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?

Do not administer the lorazepam

During a clients initial interview in a mental health inpatient setting the nurse recognizes that the client maintained eye contact and leans toward him. The nurse should conclude that the client

Is beginning to trust the nurse

A nurse is caring for a child who has Conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority?

Use a therapeutic holding technique

When admitting a client to an inpatient mental health facility, and notices that the client seems withdrawn and appears fearful. To establish a trusting nurse client relationship the nurse should first

Inform the client that her admission will be confidential

A nurse working in a clinic is assessing a client whose partner died four months ago. Which of the following statement indicates that client is at risk for complicated grief

I feel so empty without my wife it's hard to get up every morning

Caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality?

Place a large wall calendar in the clients room

Caring for a client husk it's a Fernea. The treatment plan is for the client to increase his autonomy from his parents. Prior to discharge the nurse should plan to

Schedule a family conference

Nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is of the highest priority for the nurse to report to the treatment team?

Giving away possessions

conducting a group therapy session for a client who has bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take?

Tell the client to calm down or he'll be dismissed from the session

Client was is deaf and is schedule to have ECT. The provider needs to explain the procedure to the client in order to obtain informed consent. Which of the following actions should the nurse take

Request a professional interpreter to translate

A client is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash

A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit the priority nursing intervention is to

Create a large personal space

Nurse is providing teaching to a client who is to be discharged from inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by the client indicates an understanding of the teaching?

I will use peer support to maintain my abstinence

A nurse is leading a group therapy session when a client becomes agitated and yells " listening to all of you is making me worse! " What of the following is an appropriate response?

You sound angry and frustrated. Tell me more about how you were feeling

Client was experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer?

Chlordiazepoxide

Nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the teaching

The right to treatment ensures individualized care

strategies to address suicide in the community. Which of the following should the nurse plan as a tertiary intervention?

Refer families to a grief counselor following a suicide

A nurse is reviewing the laboratory values for a client has been taking Clozapine for schizophrenia for the last three months. Which of the following laboratory findings should the nurse report to the provider?

WBC count 2500

Providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching?

Wear sunglasses when outdoors

A nurse is admitting a client who is experiencing alcohol withdrawal and appears shaky, irritable and reports nausea. Which of the following is the priority information for the nurse to obtain?

The date and time of the clients last drink

Client who has end-stage pancreatic cancer. The nurse overhears the client say to his sister I love our time together. I'm going to miss you. Which grief reaction is the client experiencing

Anticipatory

A nurse and a mental health unit observed the client has acute mania hit another client. Which the following actions should the nurse take first

Call for a team of staff members to help with the situation

nurse is conducting a private counseling session with a client who is a recent victim of intimate partner abuse. What is the final statements by the client indicates that counseling has been effective?

I feel more independent when i talk to you about what happened with my husband

A nurse is caring for a client who is scheduled to undergo ECT. Which of the following client statement indicates that further teaching is needed?

I will be able to stop taking my antidepressant after the treatment

A nurse working in a community mental health facility is teaching a client who has alcohol use disorder and is considering attending Alcoholics Anonymous. Which of the following statements by the client demonstrates an understanding of the teaching?

In AAA, I will play a role in the recovery of others who are addicted to alcohol

Caring for a client who has complulsive disorder and displays upsets of compulsive disorder which the following actions should the nurse take to assist the client to decrease the unwanted behaviors

Help the client to set time limits for compulsive behaviors

A nurse is reviewing the medical record for a client who has masochism. Which of the following information should the nurse expect in the clients history?

Fantasies involving the act of being humiliated and bound

For a client who has bipolar disorder and is taking valporic acid. Which of the following is the priority assessment finding?

The client has not slept in 24 hours

promazine 0.55 md/kg to an adolescent client who weighs 110 pounds. Available is syrup at 10 mg/5mls how many mils should the nurse administered?

14 mls

A nurse in a 24 hour mental help facility is planning to discharge a client who has a long history of alcohol use disorder. Which of the following post charge activity should the nurse plan to include

Attending a relapse prevention group several times each week

teaching about relapse prevention to a client who just began an outpatient substance use disorder treatment program. Which of the following strategies should the nurse use at the beginning of the program

Simplify program rules and objectives for the client

The nurse is planning care for a client has depression and has made frequent suicide attempts. Which of the following statement indicates that client has a decreased risk for suicide

It is easier to talk about my feelings now

Care for a preschool age child who has ADHD. Which of the following interventions is the highest priority?

Remove unnecessary equipment from the child surroundings

Teaching a client to use cognitive reframing to manage the stress of public speaking. Which of the fine statements by the client indicates an understanding of the teaching?

I know about the topic I've been asked to speak about

A nurse is caring for a client at a mental health facility who is placed in physical restraints for aggressive behavior. Which of the following behaviors indicates the client should have the restraints removed?

Follows the nurses directions

A nurses caring for a client who has paranoid schizophrenia, have been physically violent toward others and received needed doses of haloperidol IM. The nurse is preparing to administer benztropine to treat which of the following adverse affects of haloperidol

Stiff and stooped posture

Caring for a client who has recently been admitted with anorexia nervosa needs to increase oral intake. Which of the following intervention should the nurse implement?

Restrict caffeine in the diet

Client has just been told he is dying. The nurse determines that the client is going through typical early stage of grief when he says

I think my lab results got mixed up with someone else's

documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which the following findings of clinical manifestations?

Feelings of hopelessness

Flat facial expression

Angedonia

A nurse is teaching a client who is to start therapy with paroxetine. The nurse should instruct the client to report which the following findings immediately to the provider?

Fever

Caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administered first?

Diazepam 5 mg IV bolus

A nurse is caring for a client who was sexually assaulted in her home. The nurse should recognize that the client is recovering when she

Expresses interest in intimate relationships

A nurse is planning to develop a relationship with a new client

order the phrases of the nurse client relationship replacing all the letters in the correct sequence

Recognize safety risks

Set the parameters of the relationship

Promote problem solving skills

Summarize relationship goals

The nurse takes a phone call from a man who states that he is a client pastor and then asked about the clients condition. Which of the following is an appropriate response by the nurse

Put the call on hold and forward the call to the charge nurse

A nurse in a mental health facility is assessing the use of defense mechanisms in a client who has bulemia Nervosa. Which of the following client behaviors should the nurse identify as displacement.?

The client criticizes the nurse at each medication administration time

A nurse is admitting a client who is experiencing alcohol withdrawal delirium. The nurse plans a room assignment. Which of the following clients is the most appropriate roommate for this client?

A client who has depressive disorder

A nurse is having a conversation with a client who frequently becomes angry and aggressive towards others. When the client becomes verbally abusive towards the nurse, which of the following statements by the nurse is appropriate

I'm leaving now but will return in a few minutes to see if you were calmer

Case manager is implementing a program to help clients increased adherence to their treatment program which of the following actions should the nurse take?

Provide care for a clients physical health needs

A nurse is caring for a client who is in hospice for inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care which of the following interventions should the nurse implement

Discuss spiritual issues in a conversational manner

a client who has a history of alcohol use and a new diagnosis of Korsakoff syndrome. Which of the following should the nurse include in the clients plan of care?

Provide assistance with ambulation

mental health clinic is going to care for client who has a new prescription of olanzapine. Which of the following interventions is the highest priority

Instruct the client to avoid driving during initial therapy

Nurse is caring for a client who developed neuroleptic malignant syndrome or NMS As a result of taking haloperidol. After administering dantrolene IV, the nurse is to monitor the client for which of the following findings indicating that the treatment is effective?

Decreased rigidity

A nurse is receiving shift report for four clients in an acute care mental health facility. Which of the following client's should the nurse assessed first?

A client who is experiencing command hallucinations

Assessing family dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue

Older children who are responsible for their younger siblings

client who has schizophrenia with a new prescription for risperidone. Which of the following should the nurse include in the teaching?

This medication may cause an elevated blood sugar

Menstrual irregularities me occur while taking this medication

You may experience dizziness while taking this medication

mental health facility is a client who is at risk for suicide. Which of the following nursing intervention should be included in the plan of care?

Initiate discussion regarding the clients thoughts about suicide

care for an older adult client who is experiencing delirium. Which of the following interventions will meet the needs of this client?

Permit the client daily rituals to decrease anxiety

Nurse is planning to interview an older adult client to obtain a mental health history. Which of the following techniques is appropriate

Interview the client in a private setting

A nurse on a medical surgical unit is assessing a client who has a cute pancreatitis related to chronic alcohol use disorder. Which of the following is an expected finding

Epigastric pain

A nurse in a community health center is attending a health history of an older adult Who reports being abused by a caregiver. Which of the following actions is appropriate for the nurse to take

Notify a protective agency

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that she has stopped taking her lithium two weeks ago. The nurse recognizes which of the following is an expected finding that may have caused the client to stop taking the medication

Hand tremors

client who has schizophrenia and has recently attempted to commit suicide. The client is angry on admission and wants to go home. Which of the following intervention should the nurse anticipate implementing

Institute one to one observation

Administer an antidepressant medication

A nurse is providing discharge teaching for a client who has a prescription of buspirone.which of the following should the nurse include in the teaching?

Taking the medication with grapefruit juice can intensify the effects of the medication

A nurse is working with a group of older adult client in an independent living facility were discussing their plans for family reunion. Which of the following statements by a group member warrants further assessment by the nurse

I'm not going to the reunion because no one asked me to help plan it

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head and I'm going to bed! "

The nurse should document the client speech patterns as which of the following

Clang association

A nurse is planning care for a client who has excessive compulsive disorder. Which of the following is the highest priority intervention by the nurse

Help the client to identify sources of anxiety

Carefree newly admitted client who has bipolar disorder which of the following is the priority action by the nurse

Provide frequent high calorie snacks

admission assessment for a client who voluntarily entered an outpatient mental health crisis facility. The client states "I lost control of everything in my life! " Which of the following question should the nurse ask first

Are you having thoughts about harming yourself today

Caring for a client who is receiving hospice care and refusing nourishment. The client tells the nurse there's no point eating because I am dying anyway. Which of the following is a therapeutic response?

Tell me more about your concerns

four clients in a mental help facility which of the following clients is at greatest risk for injury when performing ADLs

A client who has stage six Alzheimer's disease

A nurse is caring for a client in a mental health Facility the nurse over hears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrences to the charge nurse

caring for a client who has a new prescription for lithium carbonate. Prior to administering the medication the nursery sees the client laboratory reports. The nurse should withhold the medication and call the provider based on which of the following laboratory values?

BUN 45 mg

A nurse is discussing simple restitution with the parents of the school age child who has conduct disorder. Which of the following should the nurse recommend when discussing this behavioral management technique?

Instructing the child put away the books he threw during a period of aggression

A nurse and a community mental health clinic is planning staff education about the levels of prevention of intimate partner abuse. Which of the following should the nurse identify as a strategy for primary prevention

Promoting self-esteem by having a client identify personal strengths

Caring for a client has a history of aggressive behavior. The client is playing cards and throws the cards at other clients. Which of the following interventions is appropriate in this situation?

Ask the client to express how he is feeling

community meeting for inpatient clients. One client is constantly talking and using at the majority of the groups time. Which of the following intervention should the nurse implement?

Ask the group members to discuss their feelings about this clients monopolizing behavior

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