Question 177
Question Answered step-by-step A client with Alzheimer’s disease has had recent episodes of confabulation. Theclient is most likely in which stage of Alzheimer’s? Stage 5 Stage 4 Stage 3 2.2M8EN212 2.0 points possible (graded, results hidden) Which statement made by a client in a mental health clinic demonstrates the use of denial as a coping measure? “It is my doctor’s fault that I am not improving.” “I don’t need my medication anymore.” “I am not going to come in anymore, as I have no problems.” 3.2M8EN212 2.0 points possible (graded, results hidden) A student nurse is about to take an exam and develops shortness of breath, palpitations, severe trembling, diaphoresis, dilated pupils, and chest pain. The RN would assess this as which level of anxiety? Panic Average Severe 4.1M8EN212 2.0 points possible (graded, results hidden) A client who has been diagnosed with dementia asks the RN when his wife is coming to visit. The RN knows the client has been a widow for many years. The most appropriate response by the RN would be: “You must miss your wife.” “I think your favorite TV show is on.” “Your wife died 10 years ago.” 5.1M8EN212 2.0 points possible (graded, results hidden) Which nursing intervention is the most appropriate use of behavior therapy when caring for a client with Bordorline Personality Disorder? Contract with the client to reinforce positive behaviors with rewards or privileges. Encourage the client to keep a journal of feelings to manage mood swings. Education the client on the importance of taking the antianxiety medications regularly. 6.2M8EN212 2.0 points possible (graded, results hidden) A client is taking buproprion for smoking cessation. What adverse reaction should the nurse monitor for related to this medication? Seizures Weight loss Anxiety 7.1M8EN212 2 points possible (graded, results hidden) A nurse is teaching a client about taking Lithium for his bipolar disorder. Which teaching topics should be included? Select all that apply. Serum lithium levels can be elevated by use of NSAIDS. Polyuria and thirst occur frequently as side effects of the medication. Lithium is safe to take during pregnancy. Lithium must be monitored regularly by obtaining blood levels of the medication. Lithium has a long half-life and can be taken once a day. 8.1M8EN212 2.0 points possible (graded, results hidden) The following clients have been assigned to the care of an RN on the in-patient behavioral health unit. Which client should be assessed first on the nurse’s initial rounds? A 51 year old male client with Alcoholism who was admitted yesterday for medical detoxification. A 19 year old female client with bulimia who has been vomiting in the bathroom. A 45 year old female client with depression who was admitted with suicidal thoughts one week ago. 9.2M8EN212 2.0 points possible (graded, results hidden) The client with dementia has been ordered all these medications. Which medication is indicated for agitation and wandering? rivastigmine haloperidol donepezil 10.1M8EN212 2.0 points possible (graded, results hidden) Which is the most effective nursing intervention for a client who feels no remorse for inappropriate behaviors? Explore feelings of entitlement with client. Assign consistent team member to care for client. Provide clear guidelines for behaviors. 11.1M8EN212 2.0 points possible (graded, results hidden) What is the RN’s most appropriate response to a client who is experiencing a Post-Traumatic Stress Disorder (PTSD) reaction? “What you are experiencing is not really taking place.” “Tell me what you are seeing or hearing right now.” “You are safe here and in good hands.” 12.1M8EN212 2.0 points possible (graded, results hidden) The RN who is assigned to telephone triage at the mental health outpatient clinic received all these calls over lunch time. Which call should be returned first? The client with anger management issues who just experienced a trigger. The client with schizophrenia who states they are hearing voices again. The client who takes isocarboxazid and has a severe headache. 13.2M8EN212 2.0 points possible (graded, results hidden) Which is the priority short-term outcome for the nursing diagnosis Imbalanced nutrition: less than body requirements related to binging and purging? Client will be able to identify foods and situations that are triggers. Client will negotiate a contract for percentage of meals eaten. Client will gain a prescribed amount of weight daily. 14.0M8EN212 2.0 points possible (graded, results hidden) Which nursing interventions are important for the RN to incorporate into a care plan for a client who flips the light switch 5 times whenever entering a room? Select all that apply. Orient the client to time, place and date. Administer risperidone as needed. Allow time for client to perform rituals. Provide highly structured schedule of activities. Involve the patient in group therapy activities. 15.1M8EN212 2.0 points possible (graded, results hidden) A client who lost a leg in a small plane crash is having flashbacks of the accident and has been diagnosed with Post-Traumatic Stress Disorder (PTSD). Which behavior would cause the RN to notify the Health Care Provider that the condition is worsening? Hypersomnia Restless sleep Difficulty concentrating 16.1M8EN212 2.0 points possible (graded, results hidden) A hospitalized, agitated, psychotic client refuses to take their medication. The RN calls a meeting with the healthcare team to discuss strategies to ensure the client’s safety and prevent injury. This action by the RN demonstrates which ethical principle? Nonmaleficence Beneficence Autonomy 17.1M8EN212 2.0 points possible (graded, results hidden) Which statement is the most appropriate response to a patient who is highly anxious? “You must be feeling pretty stressed right now.” “You could use some anti-anxiety medication.” “Everything will be all right, so try to relax.” 18.1M8EN212 2.0 points possible (graded, results hidden) Which intervention is most effective to minimize self-destructive behaviors when caring for a patient with Borderline Personality Disorder? Administer phenelzine as ordered for agitation. Place the patient under continuous one-on-one observation. Encourage the patient to explore triggers for the behaviors. 19.1M8EN212 2.0 points possible (graded, results hidden) Which action by the RN best demonstrates the ethical principle of beneficence as applied to a client with severe mental illness? Being honest about the client’s diagnosis, prognosis, and treatment. Acting as an advocate for the client to secure essential mental-health services. Determining how to ensure safety when the client refuses their medication. 20.1M8EN212 2.0 points possible (graded, results hidden) What is the appropriate RN response to the adult daughter of a patient with the medical diagnosis of Alzheimer’s Disease who asks the RN when the newly prescribed medication, donepezil, will begin prevention of further degeneration for her mother? “The drug does not alter the progress of the disease but temporarily relieves symptoms.” “It will take at least three months for the medication to take full effect.” “If this drug does not prevent deterioration, others can be prescribed.” 21.1M8EN212 2.0 points possible (graded, results hidden) Which is the most appropriate action by the RN when a client treated for depression states, “I am all better now, I feel great?” Observe client for suicidal ideation. Schedule an interprofessional team meeting about plans for discharge. Ask the provider to discontinue anti-depressive medication. 22.1M8EN212 2.0 points possible (graded, results hidden) The RN is caring for a woman who experienced interpersonal violence from her spouse of 15 years. Which nursing intervention would assist with empowering this patient? Identify a family member to help solve family problems. Teach her how to avoid conflicts with her spouse. Help her recognize ways she is dependent on her abuser. 23.1M8EN212 2.0 points possible (graded, results hidden) Which questions should the RN ask of a client who is at risk for suicide? Select all that Apply. Have you made a plan for suicide? Have you given away any of your personal belongings recently? Do you have friends or family that you can rely on? Have you attempted suicide in the past? Are you planning on changing jobs in the near future? 24.1M8EN212 2.0 points possible (graded, results hidden) Which behavior would first alert the RN that a co-worker might be impaired due to substance abuse? Missing medications from the medication room. Unexplained disappearances from the nursing unit. Clients reporting unrelieved pain. 25.1M8EN212 2.0 points possible (graded, results hidden) Which meal selection indicates that the client taking a Selective Serotonin Reuptake Inhibitor needs further education regarding medication safety? Macaroni and cheese, green beans, applesauce Sirloin steak, baked potato, chocolate brownie Scrambled eggs, bacon, grapefruit juice, rye toast 26.1M8EN212 2.0 points possible (graded, results hidden) The RN has selected Chronic Low Self-Esteem as the priority nursing diagnosis for a client admitted with a medical diagnosis of Depression. Which outcome is appropriate for this nursing diagnosis? The client will not harm self or others during hospitalization. The client will state side effects from prescribed medication by discharge. The client will maintain eye contact and engage in conversations with others within 48 hours. 27.1M8EN212 2.0 points possible (graded, results hidden) A client is admitted to the mental health unit who has cracked and bleeding hands secondary to their obsessive compulsion disorder. The client refuses to allow the RN to apply antibiotic ointment to their open wounds. Which action is most appropriate for the RN to take next? Set limits on further handwashing so the skin can heal. Do not apply the ointment and document the refusal. Notify the health care provider for an order for a sedative. 28.1M8EN212 2.0 points possible (graded, results hidden) A client is admitted to an inpatient psychiatric unit with the diagnosis of Paranoid Personality Disorder. Which statement made by client to the RN supports the client’s diagnosis? “I could have gone to nursing school like you, but I never had good science teachers who believed in me.” “I know we are going to be best friends by the end of today.” “I like group therapy because the other patients can feel my feelings and relate to me.” 29.1M8EN212 2.0 points possible (graded, results hidden) Which nursing intervention is the priority for a veteran with the diagnosis of post-traumatic stress disorder after returning from a military deployment? Encourage family participation in group therapy. Assess for changes in mood or cognition. Identify previously used coping strategies. 30.1M8EN212 2.0 points possible (graded, results hidden) A hospitalized adolescent who was born anatomically male has the self-perception of being female. Which of the following actions by the RN is most appropriate for this client? Orient the adolescent to reality. Perform a suicide risk assessment. Arrange for an Endocrine consultation. 31.1M8EN212 2.0 points possible (graded, results hidden) A client with schizophrenia has been taking olanzapine. Which assessment is most important to report to the provider? Shouting of obscenities. Smacking of the lips. Rocking back and forth. 32.1M8EN212 2.0 points possible (graded, results hidden) A client who had been taking low-dose chlordiazepoxide for several years verbalizes their intention to stop taking this medication. Which statement by the RN is the most appropriate? Decrease the amount of chlordiazepoxide over time. It may take 2 weeks for withdrawal symptoms to occur. Notify the provider for any muscle twitching that occurs. 33.1M8EN212 2.0 points possible (graded, results hidden) The RN should include which interventions in the plan of care for a client admitted to the emergency room after an attempted suicide? Select all that apply. Have client sign a no-suicide contract. Search the client’s belongings. Administer medications and watch the patient swallow them. Schedule regular rounding every 30 minutes. Use direct questioning to assess suicide risk. 34.1M8EN212 2.0 points possible (graded, results hidden) Which medication is most likely responsible for a client’s sudden onset of symptoms of depression? alprazolam paroxetine dextroamphetamine 35.1M8EN212 2.0 points possible (graded, results hidden) The school RN assesses a child who is complaining of a toothache for the second time this month. The RN notes a dirty and unkempt appeaerance and the presence of multiple dental caries. What is the priority action by the RN? Call the child abuse hotline. Notify the parent that the child needs to see the dentist. Notify the principal of the situation. 36.1M8EN212 2.0 points possible (graded, results hidden) Jerome, a client with Borderline Personality Disorder, begins to threaten another client who constantly interrupts a group therapy session. Which actions should the RN take? Select all that apply. Ask the other client to leave the group session. Use a calm voice to ask the other clients to leave the room. Ask the social worker and therapist to alert the other staff nurses to the situation. Command Jerome to stop the behavior or he will be sent to the isolation room. Call the provider for an order for sedation to calm Jerome. 37.1M8EN212 2.0 points possible (graded, results hidden) A toddler has been brought to the Emergency Room by the parents. Upon assessment, the RN notices round-shaped burn marks on the upper arms and thighs of the patient. Which is the most appropriate action by the RN? Ask the parent about the marks Call for consultation with social services. Contact child protective services and detain the child from discharge. 38.1M8EN212 2.0 points possible (graded, results hidden) Which statement is accurate about the admission status of a client with a longstanding history of Depression who seeks admission for psychiatric treatment due to thoughts of self-harm? The client must have next of kin sign the consent for admission The client may leave the hospital at any time unless deemed a danger to self or others. By law, the maximum duration of this admission may only be 72 hours. 39.1M8EN212 2.0 points possible (graded, results hidden) Which points should be included in the discharge teaching plan for a client with depression who has been prescribed an SSRI? Select all that apply. Once you are feeling better, slowly wean yourself off the antidepressant The phone number for a suicide hotline The medication may cause sexual dysfunction Some common side effects of SSRIs are dry mouth, headache and weight gain. Use sunblock when going outdoors 40.1M8EN212 2.0 points possible (graded, results hidden) A client who has been taking clozapine for the past two months reports sudden onset of sore throat, fever, and malaise. Which data should be reported to the health care provider immediately? Specific gravity of 1.035 White blood count of 3,000/mm3 Hematocrit of 46% 41.1M8EN212 2.0 points possible (graded, results hidden) What is the RN’s priority action for a client experiencing auditory hallucinations? Inform the health care provider. Maintain a safe environment. Tell the client that the voices are not real. 42.1M8EN212 2.0 points possible (graded, results hidden) The RN is caring for a client with Schizophrenia who states, “I am an Olympic gold medalist.” What is the most appropriate response to this statement? “Tell me more about this.” “Are you hearing voices also?” “I know you think that, but I do not believe it.” 43.1M8EN212 2.0 points possible (graded, results hidden) A client on the in-patient addictions unit criticizes himself and his family for contributing to his addiction. Which outcome would be appropriate for this client? Client states personal strengths in therapy session. Client discusses how substance abuse behaviors can be harmful to his health during group session. Client lists adaptive coping mechanisms in group therapy. 44.1M8EN212 2.0 points possible (graded, results hidden) Which intervention would be most effective for a client in Stage 4 of Azheimer’s disease? Providing meals that can be simply reheated. Provide distraction from delusions. Provide a safe, enclosed place for wandering. 45.0M8EN212 2 points possible (graded, results hidden) A client experiencing severe panic attacks has been prescribed a short-course of the medication alprazolam, with a maximum daily dose of 0.5 mg three times daily. The pharmacy label reads: How many tablets is the patient permitted to take in a 24-hour period? (in [x] tablets) Record your answer as a whole number. (Round any fractions to the nearest whole number using standard rounding rules.) Do not include words or abbreviations in your answer. 46.10M8EN212 2.0 points possible (graded, results hidden) Which statement by the patient would support a diagnosis of Somatic Symptom Disorder? “Tell me what the symptoms are and I will tell you if I have them.” “I don’t feel well but I am only here because my husband made me come.” “I keep having headaches; I know it has to be brain cancer and nothing else.” 47.1M8EN212 2.0 points possible (graded, results hidden) Which of the following characterizes an inhibited response to grieving? Denial of the emotional pain of the loss. Inability to grieve over the loss of a pet. Twenty years later, a woman talks constantly about her dead daughter. 48.1M8EN212 2.0 points possible (graded, results hidden) Which is the most appropriate nursing intervention for a client newly diagnosed and admitted with an Anxiety disorder? Explain the side effects of all medications prescribed. Explain all procedures and activities calmly. Explore the reasons and triggers for the anxiety. 49.1M8EN212 2.0 points possible (graded, results hidden) Which of the following client statements indicates that teaching about side effects of alprazolam has been effective? “I should not drink grapefruit juice while taking this medication.” “I should not consume aged cheese with this medication.” “I should not consume alcohol while taking this medication.” 50.1M8EN212 2.0 points possible (graded, results hidden) Which is the most appropriate goal for a patient with an eating disorder? A positive body image. Weight gain of ten pounds. Eating three meals per day. Health Science Science Nursing LIFE SPAN NUR212 Share QuestionEmailCopy link Comments (0)
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