A 35-year-old male patient in a general hospital's psychiatric ward believes that someone is
attempt to poison him The nurse is aware that the client's delusions are probably connected to
his A) experiences in early childhood involving issues of authority. B) resentment over being
hospitalized. C) a lack of self-worth. D) a fear of food that is phobia. A 35-year-old male client
who has been hospitalized for two weeks for chronic paranoia
maintains that someone is attempting to steal his clothes. What should the nurse do?
implement?
A) Inspire the client to actively participate in the unit's assigned activities. B) Secure the client's
closet with a lock. C) To stop these behaviors, ignore the client's paranoid thoughts. D)
Reassure the client that his suspicions are unfounded. The nurse receives a complaint from a
65-year-old female client that she has recently been hearing voices. What question should the
nurse ask this client first?
A) Are you troubled by hallucinations? B) Are you ever alone when you hear the voices?
C) Does anyone in your family suffer from hearing loss? D) Can you see what others can't? -
ANS-B A child is brought to the emergency room with a broken arm. The nurse was hurt in
another way. believes the child may have been abused. When the nurse tries to administer an
injection to the child, The child's mother shouts, "I won't leave my son!," very loudly. You must
not touch him! My kid will be hurt by you!" What is the most appropriate way to interpret the
mother's statements? The parent is A) falling back into an earlier pattern of behavior. B)
suppressing her rage. C) transferring her emotions to the nurse. D) keeping her fear at bay. -
ANS-C After a fall, a client admitted with a closed head injury has a 0.28 blood alcohol
concentration (28 percent). and is difficult to arouse. Which treatment should be administered
within the first six hours following admission? the RN determines as priority? A. Give lorazepam
(Ativan) PRN for signs of withdrawal.
B. Administer disulfiram (Antabuse) immediately.
C. Set up on your side and raise your head off the bed. D. As directed, take thiamine and
folate supplements. - ANS-C A client is admitted for alcohol withdrawal and the depressive
phase of bipolar disorder. In light of Which assessment finding will cause the RN to withhold the
prescription for clonidine (Catapres)? A. Blood pressure readings of 90/62 mmHg to 92/58
mmHg.
B. between 68 and 78 beats per minute for the pulse. C. between 99.5 and 99.7 F. D. 24
breaths per minute of respiration - ANS-A A client is admitted to the mental health unit and says
that they are taking more anxiety medication. because, "I'm so stressed out. I just want to go to
sleep." The RN ought to plan individually. the client's observation based on which statement? A.
"What ought I to do? It doesn't appear to help." B. "I have been so tired lately and needed to
sleep."
C. "I really think that I don't need to be here."
D. I'd rather not walk. Nothing matters anymore. - ANS-D