EXAM QUESTIONS WITH Correct
ANSWERS A+ Graded
1) When admitting a client to an inpatient mental health facility, a nurse notices that the
client seems withdrawn and appears fearful. To establish atrusting nurse-client
relationship, the nurse should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientationphase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past(working
phase)
2) A nurse is reviewing the potential adverse effects of lithium with a client who began
the medication 2 weeks ago. For which of the following shouldthe nurse instruct the
client to monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor (indication toxicity )
3) A nurse is caring for a child who has conduct disorder and is behaving in adestructive
manner, throwing objects, and kicking others. Which of the following therapeutic
nursing interventions is the highest priority?
a. Encourage expression of feelings (acknowledge them)
b. Promote attendance at an assertiveness training group (how to beassertive
rather than aggressive)
, c. Assist the client to perform relaxation breathing (assist the child tocalm down)
d. Use a therapeutic holding technique (the greatest risk to this child and others
is harm? Therefore, the nurse’s priority intervention is touse a therapeutic
holding technique to de-escalate the behavior andprevent injury)
4) A nurse in a mental health facility observes a client who is experiencing panic level of
anxiety. Which of the following actions should the nurse takefirst?
a. Teach the client a relaxation technique (after the attack has subsidedto prevent
further escalations of anxiety)
b. Establish an exercise routine for the client (after the attack hassubsided to
prevent further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5) A nurse is caring for a client who is taking chlorpromazine for schizophrenia.Which of
the following assessment findings indicates that the client is experiencing extrapyramidal
adverse effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascular side effect)
d. Lip smacking and tongue rolling (indicate long-term extrapyramidalside
effects associated with typical antipsychotic medications)
6) A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol
withdrawal. Available is diazepam injection 5 mg/ml. How many mLshould the nurse
administer? (round the answer to the nearest tenth. Use aleading zero if applicable. Do
not use a trailing zero.)
1.5 mL
7) A nurse is assessing a client in the emergency department. The client appears agitated,
his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are
dilated. The nurse should suspect intoxicationwith which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
, b. Cocaine (intoxication cause tachycardia, elevated blood pressure,dilated
pupils and agitation)
c. Benzodiazepines (decreased blood pressure)
d. Inhalants (central nervous system depression)
8) A nurse is educating the parent of a child who has a new diagnosis of autism
spectrum disorder. Which of the following characteristics of thisdisorder should the
nurse include in the teaching?
a. Fear of abandonment (separation anxiety disorder)
b. Language delay (autism spectrum disorder)
c. Hostile behavior (oppositional defiant disorder)
d. Motor and verbal tics (Tourette’s disorder)
9) A nurse is leading a group therapy session when a client becomes agitatedand yells,
“Listening to all of you is making me worse!” which of the following is an appropriate
response?
a. “You sound angry and frustrated. Tell us more about how you are feeling?”
( the nurse is making observations and exploring the client’sfeelings to
demonstrate caring)
b. “Maybe you would like to go to another group from now on.” (nurse’sresponse is
showing disapproval of the client and can make all of the clients defensive)
c. “Let’s not talk about this now. We will talk more about this in our individual
session.” (minimizing the client’s immediate concerns andfeelings)
d. “Do any of the other group members feel this way?”(showing disapproval of
the client and can make all of the clients defensive)
10) A home health nurse is assessing an older adult client who lives alone. Which of
the following finding should indicate to the nurse that the client isexperiencing delirium?
a. Sudden onset (suddenly over hours to days)
b. Euthymic mood ( clients who have delirium have rapid mood swings)
c. Flat affect (demonstrate expressions of feelings)
d. Slow speech (raid, inappropriate speech and language)