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1. A nurse is caring for a client who has a history of substance use disorder and was
involuntarily admitted to a mental health facility. When the nurse at- tempts to
administer oral lorazepam, the client refuses to take the medicationand becomes
physically aggressive. Which of the following actions should thenurse take?
A. Do not administer the lorazepam
,B. Request a prescription for IV lorazepam
C. Request that another nurse attempt to administer the lorazepam
D. Place the lorazepam in the client's for
.
.: Ans>> A. Do not administer the lorazepam.
Clients who are in a facility due to an involuntarily admission retain the right to refuse
treatment. Therefore, the nurse should hold the medication and document the client's
refusal.
2. A nurse is planning care for a client who has depression and has made frequent
suicide attempts. Which of the following statements indicates theclient has a
decreased risk for suicide?
A. "I'm relived now that my financial affairs are in order."
B. "It is easier to talk about my feelings now."
C. "Suddenly I have enough energy to do anything I want."
D. "Thank you for always taking such good care of me."
.
.:Ans>> B. "It is easier to talkabout my feelings now."
,When clients express their feelings, this indicates a positive treatment outcome.
3. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of thefollowing
statements should the nurse make?
A. "It will be better for you to keep busy to avoid thinking about your child'sdeath."
B. "You will complete the grieving process about a year after your child'sdeath."
C. "The grief process will start once your child actually dies."
D. "It is not uncommon to feel angry toward yourself or others."
.
.: Ans>> D. "It is notuncommon to feel angry toward yourself or others."
Feelings of blame and anger towards oneself or others are an expected reactionwhen a
client is experiencing a loss.
4. During a client's initial interview in a mental health inpatient setting, a nurse identifies
that the client is maintaining eye contact and leaning forward. Which of the following
assumptions should the nurse make based on the client's
nonverbal behaviors?
, A. The client is interested in what the nurse is saying
B. The client is attempting to manipulate the nurse
C. The client is physically attracted to the nurse
D. The client needs to feel accepted by the nurse
.
.: Ans>> A. The client is interested inwhat the nurse is saying.
The client's posture and eye contact demonstrates an interest in the interview andwhat
the nurse is saying.
5. A nurse is reviewing the electronic medical record of a client who has schizophrenia
and is taking clozapine. Which of the following findings is thepriority for the nurse to
notify the provider?
A. The client's chart indicates a 1.36 kg (3 lb.) weight gain in 1 month.
B. The client reports an inability to breathe easily.
C. The client's laboratory results indicate a fasting blood glucose level of 130mg/dL.
D. The client reports having recently started smoking cigarettes.
.
.: Ans>> B. The clientreports an inability to breathe easily.