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A nurse is assessing a client who recently used cocaine. Which of the following findings
should the nurse expect? - ANSWER Hypertension
A nurse is caring for a group of clients. Which of the following findings should the nurse
report? - ANSWER A client who is taking lamotrigine and has developed a rash
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse,.
"I hear voices telling me what to do." Which of the following actions should the nurse
take? - ANSWER Ask the client what the voices are saying.
A nurse is communicating with a client in an inpatient mental health facility. Which of the
following actions by the nurse demonstrates the use of active listening? - ANSWER
Attention to body language
A client who has paranoid schizophrenia is attending a treatment planning conference
with a family member. During the discussion of the medication adherence portion of the
plan, a nurse notices that the family member seems distracted. Which of the following
actions should the nurse take? - ANSWER Ask the family member if they have any
thoughts or questions about the treatment plan.
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The
nurse should identify that which of the following findings indicates a potential psychiatric
emergency? - ANSWER The client reports command hallucinations.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the
following medications should the nurse administer first? - ANSWER Diazepam 5 mg IV
bolus
A nurse is reviewing the electronic medical record of a client who has schizophrenia and
is taking clozapine. Which of the following findings is the priority for the nurse to notify
the provider? - ANSWER The client reports an inability to breathe easily.
, A nurse in a community health center is counseling a family of two parents and two
children. Which of the following statements by a family member indicates manipulative
behavior? - ANSWER "If you do my homework for me, I won't bother you for the rest of
the day."
A nurse is caring for a client who has schizophrenia and began taking a conventional
antipsychotic medication yesterday. Which of the following findings indicates the nurse
should administer benztropine 2 mg IM? - ANSWER Shuffling gait
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an
assistive personnel. Which of the following tasks should the nurse assign to the LPN? -
ANSWER Change the dressings of a client who has borderline personality disorder and
superficial self-inflicted wounds.
A nurse is documenting admission assessment findings for a client who has major
depressive disorder. The nurse should identify which of the following findings as clinical
manifestations? (Select all that apply.) - ANSWER Feelings of hopelessness
Anhedonia
Flat facial expression
A nurse is caring for a client who has borderline personality disorder. Which of the
following goals is the priority when planning care for this client? - ANSWER The client
will refrain from self-mutilation.
A nurse is providing teaching to a client who is to begin undergoing light therapy at
home. Which of the following information should the nurse include in the teaching? -
ANSWER Avoid looking directly at the light during treatment.
A nurse is obtaining a mental health history from an older adult client. Which of the
following actions should the nurse plan to take? - ANSWER Interview the client in a
private setting.
A nurse is discussing the home care of a client who has advanced Alzheimer's disease
with the client's partner, who is planning to go out of town for several days. Which of the
following resources should the nurse recommend to the caregiver? - ANSWER Respite
care
A nurse is caring for a client who has antisocial personality disorder and is receiving
behavioral therapy through operant conditioning. Which of the following client behaviors
indicates effectiveness of the therapy? - ANSWER Refrains from manipulating others to
earn dining room privileges