NURSING NUR 222 CAT EXAM Graded A+

1. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms? A. Introjection B. Repression C. Rationalization D. Intellectualization 2. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider? A. Knee arthroplasty 1 month ago B. Hepatitis B infection C. Recent head injury D. Hypothyroidism E. 4. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching? A. “I will provide my mother with detailed instructions about how to perform self-care.” (Give simple directions) B. “I will limit my mother’s clothing choices when she is getting dressed.” (If client is indecisive, limit the client's choices; if client still unable to make a decision, give client one outfit to wear) C. “I will wake my mother up a couple of times in the night to check on her.” D. “I will discourage my mother from talking about her physical complaints.” 27. A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship? A. Summarize goals and objectives. B. Address confidentiality. C. Promote problem-solving skills. D. Establish a participation contract 6. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? A. Identify the client’s usual coping style. A. Encourage the client to display anger toward the cause of the crisis. B. Tell the client that this life will soon return to normal (False assurance) C. Help the client focus on a wide variety of topics regarding the crisis. (Reduce stress) 18. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms? A. Suppression (Voluntarily denying unpleasant thoughts and feelings) B. Identification (Conscious or unconscious assumption of the characteristics of another individual or group) C. Compensation (Emphasizing strengths to make up for weaknesses) D. Reaction formation (Overcompensating or demonstrating the opposite behavior of what is felt) 21. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority? A. Insomnia (Sedation) B. Urinary frequency (Complication → ANTIcholinergic effects) C. High fever (Complication → agranulocytosis) D. Headache E. 30. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? A. “Keep a journal of how often you check the locks each night.” B. “Ask a family member to check the locks for you at night.” C. “Focus on abdominal breathing whenever you go to check the locks.” D. “Snap a rubber band on your wrist when you think about checking the locks.” 33. A nurse is assisting with obtaining informed consent for a client who has been legally incompetent. Which of the following actions should the nurse take? A. Explain implied consent to the client’s family. B. Contact the facility social work to obtain the consent. C. Request that the client’s guardian sign the consent D. Ask the charge nurse to obtain informed consent 46. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? A. Urine specific gravity 1.029 B. Platelets 90,000/mm C. Urine pH 5.6 D. RBC 4.7/mm 49. A nurse in a mental health facility is making plans for client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? A. Social worker B. Occupational therapist C. Clinical nurse specialist D. Recreational therapist 50. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? (ATI p.21) A. Rationalization B. Compensation C. Denial D. Displacement 59. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? A. Encourage physical activity for the client during the day. B. Keep a bright light on in the client’s room at night. C. Identify and schedule alternative group activities for the client. D. Discourage the client from expressing feelings of anger. 64. An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, “I’m so worried that my mother is depressed.” Which of the following responses should the nurse make? A. “Tell me the reasons you think your mother is depressed.” B. “You shouldn't worry about this, because depressive disorder is easily treated.” C. “Everyone gets depressed from time to time.” D. “Older adults are usually diagnosed with depressive disorder as they age.” 4. A nurse is planning care for a client who has obsessive compulsive disorder. Which of the following recommendations should the nurse include in the client’s plan of care? a. Reality orientation therapy (re-orient to reality) b. Operant conditioning (receives positive rewards for positive behavior) c. Thought stopping (say “stop” when compulsive behaviors arise & substitute w/ positive thought) d. Validation therapy (acknowledging pt’s feelings) 5. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? a. Provide in depth explanation of nursing expectations (inability to focus - give concise explanations) b. Encourage the client to participate in group activities (decrease stimulation) c. Avoid power struggles by remaining neutral (do not react personally to pt’s comments) d. Allow the client to set limits for his behavior (nurse sets limits) 7. A nurse is caring for a client who has a cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? e. Hand tremors - intoxication f. Fatigue g. Seizures - intoxication h. Rapid speech 10. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? a. Diminished reflexes b. Hypotension - increased BP c. Insomnia d. Bradycardia A nurse is caring for a client who has personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? a. Talking negatively about other staff members b. Expressing frustration regarding unit rules c. Reacting to the nurse as though she were his mother d. Refusing to participate in group activities A nurse in a mental health facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting? a. A community meeting b. A medication group c. A self-help meeting d. A symptom-management group A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Request that the client’s guardian sign the consent b. Ask the charge nurse to obtain informed consent c. Contact the facility social worker to obtain the consent d. Explain implied consent to the client’s family A nurse is assessing a client who has bipolar disorder and is taking lamtropine. Which of the following findings is the nurse’s priority? a. Thyroid-stimulating hormone (TSH) 4.0 microunits/mL b. Alanine transaminase (ALT) 20 IU/L c. Skin rash d. Epistaxis A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take? a. Manage the client’s loud, rambling, and incoherent communication patterns b. Direct the client to perform her own daily hygiene and grooming tasks c. Assist the client to identify somatic and thought-broadcasting delusions d. Use medication to decrease frequency of auditory and visual hallucination. A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Occupational therapist d. Social worker A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanism is the client demonstrating? a. Denial b. Displacement c. Compensation d. Rationalization 1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take? a. Maintain close observation of the client. 2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? a. The client is able to identify the names of family members. 3. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in this room is being recorded." Which of the following responses should the nurse make? a. "That must be very frightening." 4. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? a. Maintaining adequate hydration 5. A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The nurse should tell the client to expect which of the following adverse effects? a. Sedation 6. A nurse in a mental health unit is planning care for a client who is receiving treatment for selfinflicted injuries. The nurse should identify which of the following interventions as the priority when planning care for this client? a. Promoting and maintaining client safety 7. A nurse is providing teaching to a client who has a new prescription for disulfiram for the management of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to avoid? a. Pure vanilla extract