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.
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, 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. ,He ,attempts ,to ,comfort ,his
,wife ,by ,saying ,to ,her, ,"I ,am ,right ,here ,with ,you, ,dear. ,Nothing ,can ,keep ,us ,apart." ,What ,is ,the
,priority ,nursing ,intervention? ,- ,CORRECT ,ANSWER-Require ,the ,husband ,to ,leave ,the ,cubicle
,while ,the ,client ,is ,being ,treated.
A ,female ,client ,with ,severe ,depression ,is ,given ,information ,about ,the ,risks, ,benefits,
,alternatives, ,and ,expected ,outcomes ,of ,electroconvulsive ,therapy ,(ECT) ,and ,signs ,the
,informed ,consent ,for ,treatment. ,After ,the ,client's ,family ,leaves, ,the ,client ,tells ,the ,nurse, ,"I
,signed ,the ,papers ,because ,my ,husband ,told ,me ,I ,will ,be ,deported ,if ,my ,depression ,is ,not
,cured." ,What ,information ,should ,the ,nurse ,report ,to ,the ,healthcare ,provider? ,- ,CORRECT
,ANSWER-The ,client's ,consent ,may ,have ,been ,coerced.
A ,male ,client ,with ,severe ,orthopedic ,injuries ,following ,a ,motor ,vehicle ,collision ,is ,irritable,
,angry, ,and ,belittles ,the ,nurses. ,While ,a ,nurse ,is ,changing ,the ,dressing ,over ,a ,laceration, ,the
,client ,screams, ,"Don't ,touch ,me! ,You're ,so ,stupid ,that ,you'll ,make ,it ,worse!" ,Which ,intervention
,is ,best ,for ,the ,nurse ,to ,implement? ,- ,CORRECT ,ANSWER-Provide ,information ,about ,infection
,prevention.
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