and Well Updated Answers_2025
The nurse completes an emergency admission of a male client with schizophrenia who
has not been taking his antipsychotic medications. The client is pacing, is extremely
irritable, and has a blood pressure of 146/96. What is the priority nursing action?
(Correct Answer) - ✅✅ Reevaluate the client's blood pressure in an hour.
A young adult female client with panic disorder arrives in the Emergency Center with a 4-
day history of chest pain that began when her boyfriend left her. Initial assessment
reveals normal cardiopulmonary findings. Which information is most important for the
nurse to obtain? (Correct Answer) - ✅✅ Drugs taken in last 7 days.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells
the nurse, "There wasn't anything I could do to stop her drinking this morning." What
intervention should the nurse take at this time? (Correct Answer) - ✅✅ Tell the client
that therapy cannot take place while she is intoxicated.
The nurse is planning care for a client with major depression who is admitted to the unit
after a recent suicide attempt. Which intervention has the highest priority for inclusion in
this client's plan of care? (Correct Answer) - ✅✅ Search the client's personal
belongings.
A male client is brought to the emergency department by a police officer, who reports the
client was "disturbing the peace" by running naked in the street, striking out at others,
and smashing car windows. Which behaviors should the client demonstrate to determine
if he should be evaluated for involuntary commitment? (Choose all that apply.) (Correct
Answer) - ✅✅ Threats to kill his friend, hears voices telling him to kill himself, reports
he has not needed a bath in 4 months and says he has not eaten in 3 days.
, The nurse is caring for an adult male client with catatonic schizophrenia who is mute and
motionless. What is the priority nursing problem? (Correct Answer) - ✅✅ High risk
for fluid and electrolyte imbalance.
At the end of a group therapy session, a client who is hospitalized for psychosis falls to
the floor when attempting to stand. What intervention should the nurse implement first?
(Correct Answer) - ✅✅ Ask a group member to seek help.
Which nursing intervention should the nurse implement with parents who experience a
fetal demise and express the wish not to see the baby? (Correct Answer) - ✅✅ Keep
the body available for a few hours in case they change their minds.
An adult female who is married and works full-time in a factory has been absent from
work for three days at a time on several occasions. Each time she returns to work, she
wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational
health nurse. What assessment question should the nurse use? (Correct Answer) - ✅✅
How did this happen to you?
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should
initiate a referral to which healthcare team member? (Correct Answer) - ✅✅ Dietician.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care? (Correct Answer) - ✅✅
Focus on the client's positive or negative feelings toward the nurse.
A woman admitted to the Emergency Department is bleeding profusely from a patch
where hair was lost from her scalp. She is accompanied by her husband who tells the
nurse that his wife caught her hair on the railing and pulled it out when she fell down the
stairs. The husband is solicitous of his wife and quickly answers questions on her behalf.