1. A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the following findings is the
priority for the nurse to report to the provider?
A. Elevated blood pressure.
B. Weight gain.
C. Muscle twitching.
D. 2+ peripheral edema
A. Elevated blood pressure
Explanation: increases the risk of a hypertensive crisis that can result from taking an MAOI like phenelzine.
2. A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, "Have I done any permanent
damage to my body?" Which of the following responses should the nurse provide?
A. "What concerns do you have about your physical health?"
B. "Let's wait to discuss that until after you're feeling better."
C. "Unconsciously, you're admitting you're worried about your physical appearance."
D. "I'm glad to hear that you're concerned about the physical effects of your illness."
A. "What concerns do you have about your physical health?"
Explanation: This statement by the nurse is an example of exploring, which is a therapeutic communication technique that
encourages the client to talk further about personal feelings and perceptions.
, 3. A nurse is communicating with a client at an inpatient mental health facility. Which of the following actions by the nurse
demonstrates the proper use of active listening?
A. Offering self
B. Using silence
C. Paying attention to body language.
D. Reflecting feelings
C. Paying attention to body language.
Explanation: Active listening involves identifying verbal and nonverbal communication by the client, which includes paying
attention to body language.
4. A nurse if caring for a client who has schizophrenia and is admitted to the mental health unit. The client has a history of
aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following
responses should the nurse make?
A. "It's a beautiful day outside. Let's take a walk together."
B. "Sit down and we'll try out a relaxation exercise."
C. "Would you like your anti-anxiety medication now?"
D. "You are pacing back and forth. Can you tell me what you are feeling?"
D. "You are pacing back and forth. Can you tell me what you are feeling?"
Explanation: Using the nursing process, the nurse should first collect data from the client. By asking the client to identify
feelings of anxiety, the nurse promotes trust and can assist the client with decreasing anxiety before an episode of aggression
occurs.
priority for the nurse to report to the provider?
A. Elevated blood pressure.
B. Weight gain.
C. Muscle twitching.
D. 2+ peripheral edema
A. Elevated blood pressure
Explanation: increases the risk of a hypertensive crisis that can result from taking an MAOI like phenelzine.
2. A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, "Have I done any permanent
damage to my body?" Which of the following responses should the nurse provide?
A. "What concerns do you have about your physical health?"
B. "Let's wait to discuss that until after you're feeling better."
C. "Unconsciously, you're admitting you're worried about your physical appearance."
D. "I'm glad to hear that you're concerned about the physical effects of your illness."
A. "What concerns do you have about your physical health?"
Explanation: This statement by the nurse is an example of exploring, which is a therapeutic communication technique that
encourages the client to talk further about personal feelings and perceptions.
, 3. A nurse is communicating with a client at an inpatient mental health facility. Which of the following actions by the nurse
demonstrates the proper use of active listening?
A. Offering self
B. Using silence
C. Paying attention to body language.
D. Reflecting feelings
C. Paying attention to body language.
Explanation: Active listening involves identifying verbal and nonverbal communication by the client, which includes paying
attention to body language.
4. A nurse if caring for a client who has schizophrenia and is admitted to the mental health unit. The client has a history of
aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following
responses should the nurse make?
A. "It's a beautiful day outside. Let's take a walk together."
B. "Sit down and we'll try out a relaxation exercise."
C. "Would you like your anti-anxiety medication now?"
D. "You are pacing back and forth. Can you tell me what you are feeling?"
D. "You are pacing back and forth. Can you tell me what you are feeling?"
Explanation: Using the nursing process, the nurse should first collect data from the client. By asking the client to identify
feelings of anxiety, the nurse promotes trust and can assist the client with decreasing anxiety before an episode of aggression
occurs.
