ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE

ATI MENTAL HEALTH PRACTICE- LATEST BEST GUIDE REVISION GUIDE TO EXAM BEST SCORES The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? A) The client spends more time by himself B) The client doesn't engage in delusional thinking C) The client doesn't harm himself or others D) The client demonstrates ability to meet his own self-care needs The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? A) Helping the client to participate in social interactions B) Establishing a one-on-one relationship with the client C) Establishing alternative forms of communication D) Allowing the client to decide when he wants to participate in verbal communication with the nurse Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? A) Dismantling the showerhead and showing the client that there is nothing in it B) Explaining that other clients are complaining about the client's body odor C) Asking a security officer to assist in giving the client a shower D) Accepting these fears and allowing the client to take a sponge bath Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction? A) Hypertension B) Respiratory arrest C) Tourette Syndrome D) Retinal pigmentation A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse? A) "I get upset once in a while, too." B) "I know just how you feel. I'd feel the same way in your situation." C) "I worry, too, when I think people are talking about me." D) "At times, it's normal not to trust anyone." How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated? A) Several minutes B) Several hours C) Several days D) Several weeks A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? A) Take the medication 1 hour before a meal. B) Decrease the dosage if signs of illness decrease C)Apply a sunscreen before being exposed to the sun. D) Increase the dosage up to 50 mg twice per day if signs of illness don't decrease. A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? A) "Your behavior won't be tolerated. Go to your room immediately." B) "You're just doing this to get back at me for making you come to therapy." C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." D) "I'm disappointed in you. You can't control yourself even for a few minutes." Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)? A) The absence of anticholinergic effects B) A lower incidence of extrapyramidal effects C) Photosensitivity and sedation D) No incidence of neuroleptic malignant syndrome The etiology of schizophrenia is best described by: A) genetics due to a faulty dopamine receptor. B) environmental factors and poor parenting. C) structural and neurobiological factors. D) a combination of biological, psychological, and environmental factors. A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A) benztropine (Cogentin) B) dantrolene (Dantrium) C) clonazepam (Klonopin) D) diazepam (Valium) A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response? A) Say, "You know it's your medicine." B) Allow him to open the individual wrappers of the medication. C) Say, "Don't worry about what is in the pills. It's what is ordered." D) Ignore the comment because it's probably a joke. A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? A) "That must be frightening to you. Can you tell me how you feel about it?" B) "There are no people living on Mars." C) "What do you mean when you say they're going to invade the earth?" D) "I know you believe the earth is going to be invaded, but I don't believe that." A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he: A) sit in a quiet, dark room and concentrate on the voices. B) listen to a personal stereo through headphones and sing along with the music. C) call a friend and discuss the voices and his feelings about them. D) engage in strenuous exercise. A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client? A) Ineffective protection related to blood dyscrasias B) Urinary frequency related to adverse effects of antipsychotic medication C) Risk for injury related to a severely decreased level of consciousness D) Risk for injury related to electrolyte disturbances A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? A) Dystonia B) Akathisia C) Pseudoparkinsonism D) Tardive dyskinesia An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease. A) Meeting all of the client's physical needs B) Giving the client an opportunity to express concerns C) Administering lithium carbonate (Lithonate) as prescribed D) Providing a quiet environment where the client can be alone A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client? A) chlorpromazine (Thorazine) B) imipramine (Tofranil) C) lithium carbonate (Lithane) D) fluphenazine decanoate (Prolixin Decanoate) A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction? A) Dystonia B) Akanesia C) Akathisia D) Tardive dyskinesia Hormonal effects of the antipsychotic medications include which of the following? A) Retrograde ejaculation and gynecomastia B) Dysmenorrhea and increased vaginal bleeding C) Polydipsia and dysmenorrhea D) Akinesia and dysphasia with positive mental health. Your friend has just been laid off from his job. Which of the following responses on your part would most likely contribute to his enhanced resilience? a. using your connections to set up an interview with your employer b. connecting him with a friend of the family who owns his own business c. supporting him in arranging, preparing for, and completing multiple interviews d. helping him to understand that the layoff resulted from troubles in the economy and is not his fault A nurse's identification badge includes the term, Psychiatric Mental Health Nurse. A patient with a history of paranoia asks, "What does that title mean?" The nurse responds best by answering with which of the following? a. "Don't be afraid; it means I'm here to help, not hurt, you." b. "Psychiatric mental health nurses care for people with mental illnesses." c. "We have the specialized skills needed to care for people with mental illnesses." d. "The nurses who work in mental health facilities have that title." A patient tells the mental health nurse, "I am terribly frightened! I hear whispering that someone is going to kill me." Which criterion of mental health can the nurse assess as lacking? a. Control over behaviour b. Accurate appraisal of reality c. Effectiveness in work d. Healthy self-concept A 14-year-old belongs to a gang that bullies and punishes other teens, engages in sexually promiscuous behaviour, attends school infrequently and argues with her parents, claiming they are just old-fashioned and don't understand her. What does the assessment data support about the patient? a. That she is exhibiting problems related to conduct and behaviour b. That she cannot accurately appraise reality c. That she is seriously and persistently mentally ill d. That she should be considered for group home placement A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: 1. echolalia 2. an idea of reference 3. a delusion of infidelity 4. an auditory hallucination A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?: 1. echolalia 2. waxy flexibility 3. depersonalization 4. thought withdrawal The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?: 1. auditory hallucinations 2. delusions of grandeur 3. poor personal hygiene 4. psychomotor agitation A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question: 1. "How long has the voice been directing your behavior?" 2. "Does what the voice tell you to do frighten you?" 3. "Do you recognize the voice speaking to you?' 4. "What is the voice telling you to do?" A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?: 1. powerlessness 2. social isolation 3. risk for suicide 4. compromised family coping A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?: 1. "Are you having thoughts of suicide?" 2. "I am not sure I understand what you are trying to say." 3. "Try to stay hopeful. Things have a way of working out." 4. "Tell me more about what interested you before you became depressed." A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply: 1. imbalanced nutrition: more than body requirements 2. disturbed thought processes 3. sleep deprivation 4. chronic confusion 5. social isolation The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply: 1. touch the patient to provide reassurance 2. invite the patient to lead a community meeting 3. provide a structured environment for the patient 4. ensure that the patient's nutritional needs are met 5. design activities that require the patient's concentration The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply: 1. channeling excessive energy 2. reducing guilty ruminations 3. instilling a sense of hopefulness 4. assisting with self-care activities 5. accommodating psychomotor retardation Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply: 1. maintain arm's-length, one-on-one direct observation at all times 2. check all items brought by visitors and remove risk items 3. use plastic eating utensils; count utensils upon collection 4. remove the patient's eyeglasses to prevent self-injury 5. interact with the patient every 15 minutes A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?: 1. discourage rest periods during the daytime 2. instruct family to avoid visiting during mealtimes 3. offer 3 or 4 large meals/day 4. give the client extra time to communicate needs A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?: 1. temporary memory loss is the most common adverse effect of ECT 2. medications are given to prevent seizure activity during ECT 3. the greatest risk of ECT is brain damage 4. ECT is effective in the treatment of substance use disorders A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?: 1. encouraging decision-making 2. giving the client choices of activities 3. playing a game of chess with the client 4. spending time sitting with the client A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?: 1. "You really need to follow the rules of the unit and get out of bed." 2. "If you do not get out of bed you will not receive your meal." 3. "I will help you get ready and then you can rest after activities." 4. "You should rest until you feel able to join the group." A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?: 1. sit with the client and offer simple, direct information 2. have the client attend group therapy immediately 3. explain the unit policies to the client and answer any questions he might have 4. take the client on a tour of the unit and introduce him to all the staff members on duty A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for Buproprion. Which of the following statements by the client indicates understanding of the teaching?: 1. "I may develop a slow heartbeat while taking Bupropion." 2. "I can drink one glass of wine with dinner each day while taking Bupropion." 3. "I may not notice a lifting of my mood for at least 2 weeks." 4. "I should watch for increased salivation and drooling while taking Bupropion." A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation?: 1. "I had a great trip to the Smokey Mountains." 2. "Going back to work has been okay." 3. "I just don't like going to the movies like I used to." 4. "I can't wait to have my family together next weekend." A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm really feeling down and don't want to talk to anyone right now." Which of the following responses should the nurse make?: 1. "It might help you feel better if you talk about it." 2. "I'll just sit here with you for a few minutes then." 3. "I understand. I've felt like that before, too." 4. "Why are you feeling so down?" A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?: 1. "Everyone feels better after showering." 2. "You must be getting better. You look great!" 3. "I see you have done some grooming today." 4. "Why are you all dressed up today? Is it a special occasion?" A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?: 1. encourage family to take the client out of the facility for short periods of time 2. reward the client for her change in behavior 3. monitor the client's whereabouts at all time 4. ask the client why her behavior has changed A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?: 1. ask the client if she has a plan to commit suicide 2. recognize the attempt at manipulation and escort the client back to her activity 3. assist the client to her room allowing her to rest before resuming activity 4. notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching?: 1. "I need to make a voluntary choice to stop feeling depressed." 2. "I can cure my depression by thinking positive thoughts." 3. "I will attend psychotherapy to help manage my depression." 4. "I will plan on my antidepressant taking 3-5 days to be effective." A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? 1. being married 2. pregnancy 3. male gender 4. chronic illness A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply): 1. request an ECG 2. witness the informed consent 3. check the client's blood pressure 4. obtain a serum parathyroid hormone level 5. obtain a urine specimen A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?: 1. a semi-private room across from the day room 2. a private room across the nurse's station 3. a private room across from the exercise room 4. a semi-private room across from the snack area A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?: 1. flight of ideas 2. grandiosity 3. reality testing 4. Derealization A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?: 1. provide a stimulating environment 2. have consistent unit routines 3. discourage daytime napping 4. schedule daily seclusion times A nurse in an acute mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?: 1. the client has begun playing basketball with several other clients during the past month 2. the client identifies with problems expressed by other clients 3. the client's behavior has become impulsive in the past few weeks 4. the client states that she wants to go home to be with her children and partner A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?: 1. Fluvastatin 2. Carbamazepine 3. Lorazepam 4. Propranol A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply). 1. Paroxetine 2. Lithium 3. Donepezil 4. Valproate 5. Carbamazepine A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?: 1. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." 2. "Come with me. Here is a milkshake to drink." 3. "We need you to decide what activities you will do today." 4. "You will need to leave the dining room right now and go somewhere else to exercise." The defense mechanisms that can be used in only healthy ways include which of the following? a. Suppression and humour b. Altruism and sublimation c. Idealization and splitting d. Reaction formation and denial A person recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor. This person is demonstrating which of the following defence mechanisms? a. Projection b. Rationalization c. Reaction formation d. Undoing A man continues to speak of his wife as though she were still alive, 3 years after her death. This behaviour suggests the use of which of the following defence mechanisms? a. Altruism b. Denial c. Undoing d. Suppression What can be said about the comorbidity of anxiety disorders? a. Anxiety disorders generally exist alone. b. A second anxiety disorder may coexist with the first. c. Anxiety disorders virtually never coexist with mood disorders. d. Substance abuse disorders rarely coexist with anxiety disorders. Studies of patients diagnosed with post-traumatic stress disorder suggest that the stress response of which of the following is considered abnormal? a. Brain stem b. Hypothalamus-pituitary-adrenal system c. Frontal lobe d. Limbic system An obsession is defined as which of the following? a. Thinking of an action and immediately taking the action. b. A recurrent, persistent thought or impulse. c. An intense irrational fear of an object or situation. d. A recurrent behaviour performed in the same manner. Which of the following is a symptom commonly associated with panic attacks? a. Obsessions b. Apathy c. Fever d. Fear of impending doom Working to help the patient view an occurrence in a more positive light is called which of the following? a. Flooding b. Desensitization c. Response prevention d. Cognitive restructuring Which of the following is the primary purpose of performing a physical examination before beginning treatment for any anxiety disorder? a. Protect the nurse legally b. Establish the nursing diagnosis of priority c. Obtain information about the patient's psychosocial background d. Determine whether the anxiety is primary or secondary in origin Which of the following is an important question to ask during the assessment of a patient diagnosed with anxiety disorder? a. "How often do you hear voices?" b. "Have you ever considered suicide?" c. "How long has your memory been bad?" d. "Do your thoughts always seem jumbled?" Which of the following is a possible outcome criterion for a patient diagnosed with anxiety disorder? a. Patient demonstrates effective coping strategies b. Patient reports reduced hallucinations c. Patient reports feelings of tension and fatigue d. Patient demonstrates persistent avoidance behaviours Inability to leave one's home because of avoidance of severe anxiety suggests which of the following anxiety disorders? a. Panic attacks with agoraphobia b. Obsessive-compulsive disorder c Post-traumatic stress response d. Generalized anxiety disorder A teenager changes study habits to earn better grades after initially failing a test. This behavioural change is likely a result of which of the following? a. A rude awakening b. Normal anxiety c. Trait anxiety d. Altruism A young adult applying for a position is mildly tense but eager to begin the interview. This can be assessed as showing which of the following? a. Denial b. Compensation c. Normal anxiety d. Selective inattention A patient frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the patient's level of anxiety as which of the following? a. Mild b. Moderate c. Severe d. Panic A patient is displaying symptomatology reflective of a panic attack. In order to help the patient regain control, how does the nurse respond? a. "You need to calm yourself." b. "What is it that you would like me to do to help you?" c. "Can you tell me what you were feeling just before your attack?" d. "I will get you some medication to help calm you." A patient who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." Which of the following would be a helpful response for the nurse to make? a. "What things have you done in the past that helped you feel more comfortable?" b. "Let's try to focus on that adorable little granddaughter of yours." c. "Why don't you sit down over there and work on that jigsaw puzzle?" d. "Try not to think about the feelings and sensations you're experiencing." Which of the following is a cultural characteristic that may be observed in a teenage, female Hispanic patient in times of stress? a. To suddenly tremble severely b. To exhibit stoic behaviour c. To report both nausea and vomiting d. To laugh inappropriately The nurse anticipates that the nursing history of a patient diagnosed with obsessive-compulsive disorder (OCD) will reveal which of the following? a. A history of childhood trauma b. A sibling with the disorder c. An eating disorder d. A phobia as well A patient is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the patient reports which of the following? a. That his symptoms started right after he was robbed at gunpoint b. Being so worried he hasn't been able to work for the last 12 months c. That eating in public makes him extremely uncomfortable d. Repeatedly verbalizing his prayers helps him feel relaxed If a patient's record mentions that the patient habitually relies on rationalization, the nurse might expect the patient to do which of the following? a. Make jokes to relieve tension b. Miss appointments c. Justify illogical ideas and feelings d. Behave in ways that are the opposite of his or her feelings Panic attacks in Latin American individuals often involve which of the following? a. Repetitive involuntary actions b. Blushing c. Fear of dying d. Offensive verbalizations The plan of care for a patient who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? a. Having the patient repeatedly touch "dirty" objects b. Not allowing the patient to seek reassurance from staff c. Not allowing the patient to wash hands after touching a "dirty" object d. Telling the patient that he or she must relax whenever tension mounts A patient is experiencing a panic attack. The nurse can be most therapeutic by doing which of the following? a. Telling the patient to take slow, deep breaths b. Verbalizing mild disapproval of the anxious behaviour c. Asking the patient what he means when he says "I am dying" d. Offering an explanation about why the symptoms are occurring The nurse caring for a patient experiencing a panic attack anticipates that the psychiatrist would order a stat dose of which of the following? a. Standard antipsychotic medication b. Tricyclic antidepressant medication c. Anticholinergic medication d. A short-acting benzodiazepine medication A military veteran is entering treatment for post-traumatic stress disorder following after a return from duty in Afghanistan. Which of the following is an important facet of assessment? a. Ascertain how long ago the trauma occurred b. Find out if the patient uses acting-out behaviour c. Determine use of chemical substances for anxiety relief d. Establish whether the patient has chronic hypertension related to high anxiety When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should do which of the following? a. Question the physician's order because the dose is excessive b. Explain the long-term nature of benzodiazepine therapy c. Teach the patient to limit caffeine intake d. Tell the patient to expect mild insomnia Which nursing diagnosis would be most useful for patients with anxiety disorders? a. Excess fluid volume b. Disturbed body image c. Ineffective role performance d. Disturbed personal identity A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?: 1. reviewing the client's toxicology laboratory report 2. making a contract with the client for eating behvior 3. initiating suicide precautions 4. administering the Hamilton Depression Scale 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 the following statements should the nurse make A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A. A client wants to know the current time while there is a clock on the wall. B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees C (78 F). D. A client refuses to get out of bed and has no motivation to attend to daily hygiene. A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A. Decreased auditory and visual acuity. B. Decreased display of emotion. C. Personality traits that are opposite of original traits. D. Forgetfulness gradually progressing to disorientation. A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.) A. Ability to perform calculations B. Level of consciousness C. Recall ability D. Long-term memory E. Level of orientation A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, " I want to go home; my husband is waiting for me to cook dinner. "Which of the following responses by the nurse is appropriate? A. " this is where you live now." B. " this is a safer place for you to live." C. "Tell me what you like to cook for dinner." D. "Your family said there is no one to care for you at home." A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A. rotate assignment of daily caregivers. B. provide an activity schedule that changes from day to day. C. limit time for the client to perform activities. D. talk the client through tasks one step at a time. A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room with dim lighting D. A room containing personal belongings The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet response to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the clients behavior? A. he is hard of hearing B. pain C. confusion D. language barrier A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.) A. grooming B. long-term memory C. support systems D. affect E. presence of pain A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A. assist the client to the correct room. B. place the client in restraints. C. re-orient the client to time and place. D. move the client to a room at the end of the hall. A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. post a written schedule of daily activities. B. use an overhead loudspeaker to announce events. C. provide a consistent daily routine. D. allow the client to choose free time activities. A nurse is monitoring a client who is post operative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.) A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness A nurse is caring for a client who is one day post operative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? A. determine the time the client last received pain medication. B. Measure the clients vital signs, including temperature. C. ask the client to rate her pain on a scale of from 0 to 10. D. re-position the client and offer her a back rub. A nurse is planning care for a client who is post operative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) A. use of analgesics will eventually lead to addiction. B. each clients expression of pain may be different and individualized. C. Patient controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and tolerance can be assessed using a scale from 0 to 10. E. The client will express the feeling of pain both verbally and nonverbally. A nurse is caring for a client your request prescription pain medication. Which of the following actions should the nurse perform first? A. re-position the client. B. administer the medication. C. determine the location of the pain. D. review the effects of the pain medication. A nurse is applying a cold compress for a client who has pain and minor swelling in a suture laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. inspecting the site for reduced swelling B. monitoring the clients pulse rate C. asking the client to rate the pain D. having the client perform range of motion of the affected arm A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? A. set the pad's temperature to 47.2°C B. stop the treatment if the client's skin becomes red C. leave the pad in place for at least 40 minutes D. use safety pins to keep the pad in place A nurse is caring for a client who is post operative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. vital sign measurement B. The clients self report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure A nurse is caring for a client who requires cold applications with an ice bag to reduce The swelling and pain of an angle injury. Which of the following actions should the nurse take? A. apply the bag for 30 minutes at a time. B. Reapply the bag 10 minutes after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin. A nurse is caring for a client who is post operative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) A. offer the client a back rub. B. Remind the client to use incisional splinting. C. Identify the clients pain level. D. Assist the client to ambulate. E. Change the client's position. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. vital signs B. self report of pain C. severity of the condition D. nonverbal behavior As stress increases, the person is more susceptible to changes in health such as increased risk for: CONTINUED.....................DOWNLOAD FOR MORE REVISION