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1. A nurse in the emergency room is Respiratory depression
collecting data from a client who has
heroin intoxication. Which of the fol- *Heroin is an opioid; therefore, the nurse should
lowing findings should the nurse ex- expect this client who has heroin intoxication to
pect? exhibit respiratory depression.
A. Seizure activity
B. Respiratory depression
C. Hypersensitivity to pain
D. Increased mental alertness
2. A nurse on a mental health unit is The client has a history of violence
caring for a client who is displaying
signs of anger. Which of the follow- *The client's history of violence is the most impor-
ing pieces of information about the tant indicator that this client might become violent;
client is the strongest indicator that therefore, this is the strongest indicator of poten-
the client might become aggressive? tial aggressiveness.
A. The client has marginal coping
skills
B. The client has a history of violence
C. The client feels powerless after be-
ing hospitalized
D. The client blames others for her
problems
3. A nurse is reinforcing teaching with Offer finger foods to the client
the caregiver of a client who has de-
mentia. Which of the following in- *The caregiver should offer finger foods that the
structions should the nurse include in client can eat without sitting down. Clients who
the teaching? have dementia often like to wander and walk off
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A. Offer the client a list of activities to nervous energy, which can decrease anxiety and
choose from calm the client.
B. Offer finger foods to the client
C. Discourage naps throughout the
day
D. Turn on the television when the
client is in the room
4. A nurse is contributing to the plan of Encourage the client to have frequent rest periods
care for a client with bipolar disor-
der who has acute mania. Which of *The nurse should recommend encouraging fre-
the following interventions should the quent rest periods throughout the day to decrease
nurse recommend including in the the client's risk of exhaustion from the constant
plan? activity associated with acute mania.
A. Provide the client with a low-calorie,
low-fat diet
B. Encourage the client to have fre-
quent rest periods
C. Escort the client to daily group ther-
apy
D. Limit the client's intake of caffeinat-
ed beverages to 12 oz per day
5. A nurse is reviewing the plan of care Helps the client deal with distorted thought
for a client who has bipolar disorder. processes
Which of the following is an effect
of using cognitive behavioral therapy*CBT assists the client with recognizing distorted
thought processes that are maladaptive with re-
(CBT) for a client who has bipolar dis-
order? gards to recovery. When experiencing mania, the
client tends to view the future unrealistically as
A. Prevents the need for mood-stabi- highly favorable. CBT assists the client in recogniz-
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lizing medications ing and challenging such unrealistic or "automatic"
B. Helps the client deal with distorted thoughts and can help the client and the health
thought processes care team recognize early trends toward mania
C. Aids in communication among fam-
ily members
D. Replaces the need for lifestyle in-
terventions
6. A nurse is caring for a client in a men- Notify the provider of the client's threat
tal health facility and overhears the
client discussing plans to harm her fa- *It is the nurse's duty to notify the provider of the
ther-in-law physically when she is dis- client's threat. It will then be the provider's respon-
charged. Which of the following inter- sibility to warn the the intended victim or the police
ventions should the nurse take? of the client's threat
A. Ask the client to sign a contract
agreeing not to harm others
B. Notify the provider of the client's
threat
C. Keep the client's discussion confi-
dential
D. Place the client in individual obser-
vation
7. A nurse is preparing to meet with a Facilitate change in the client's behavior
client who has borderline personality
disorder. Which of the following ac- *The nurse should facilitate change in the client's
tions should the nurse plan to take behavior during the working phase of the thera-
during the working phase of the ther- peutic relationship.
apeutic relationship?
A. Introduce the concept of client con-
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fidentiality
B. Establish goals with the client
C. Define the roles of the nurse and
the client
D. Facilitate change in the client's be-
havior
8. A nurse is contributing to the plan Search the client and his belongings upon arrival
of care for a client who has suici-
dal ideation and is being transferred *The nurse should plan to search the client and
to the mental health unit. Which of all of his belongings upon arrival to the unit. This
the following interventions should the search is conducted for the client's safety so that
nurse recommend? the nurse can identify and remove any objects that
increase the client's risk of injury or suicide. Poten-
A. Search the client and his belong- tially harmfully objects include razors, shoelaces,
ings upon arrival hygiene products, and tweezers
B. Assign the client to a private room
near the nurse's station
C. Instruct assistive personnel to
check on the client every 15 m in
D. Keep the door to the client's room
closed
9. A nurse is talking with a client about "It sounds like you are concerned about your fam-
his admission to a mental health unit. ily's reaction."
The client states, "I just don't know if
I should be here. What will my fam- *In a reflective response, the nurse directs feelings
ily think?" Which of the following re- and statements back to the client, allowing the
sponses by the nurse uses the ther- client to think about personal feelings
apeutic communication technique of
reflection?