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A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose f
amily reports episodes of confusion. Which of the following assessment findings supports the nurse's s
uspicion of delirium? - correct answer-Easily distracted
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements sho
uld the nurse make? - correct answer-"I'll stay with you just in case you want to talk."
A nurse is caring for four clients in an emergency department. The nurse should identify that which of
the following clients can give informed consent? - correct answer-A 35-year-
old client who has major depressive disorder
A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive di
sorders. Which of the following statements by the newly licensed nurse indicates an understanding of t
he teaching? - correct answer-
"I will update the plan of care as a client's manifestations of depression change."
A nurse on a medical-
surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-
vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findi
ngs should indicate to the nurse that the client is experiencing alcohol withdrawal? - correct answer-
Blood pressure 154/96 mm Hg
A nurse is planning care for a client who has made repeated physical threats toward others on the unit.
Although the client does not want to leave the unit, the nurse requests the provider to transfer the clie
nt to a unit that is equipped to manage violent behavior. Which of the following ethical principles shou
ld the nurse apply in this situation? - correct answer-Nonmaleficence
A nurse is discussing a 12-
step program with a client who has alcohol use disorder and is in an acute care facility undergoing det
oxification. Which of the following information should the nurse include in the teaching? -
, correct answer-
The client should obtain a sponsor before discharge for an increased chance of recovery.
A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to har
m others on the unit. Which of the following interventions should the nurse include in the plan? -
correct answer-Renew the prescription for the client every 4 hr.
A nurse is performing an admission assessment on a client and notices that the client appears withdraw
n and fearful. To establish a trusting nurse-
client relationship, which of the following actions should the nurse take first? - correct answer-
Inform the client that this admission is confidential.
A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse
should identify that which of the following treatment options can offer interdisciplinary services for the
client at home? - correct answer-Assertive community treatment
A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the
nurse is an example of the ethical principle of justice? - correct answer-
Spending adequate time with a client who is verbally abusive.
A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa
. Which of the following statements made by the guardians indicates an understanding of their child's i
llness? - correct answer-"It is important for our child to have regular dental checkups."
A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline fo
r 1 week. Which of the following outcomes should the nurse expect? - correct answer-
Greater risk of attempting suicide as affect and energy improve
A nurse is planning care for a client who has generalized anxiety disorder. At which of the following l
evels of anxiety should the nurse plan to teach the client relaxation techniques? - correct answer-Mild
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal
body weight. Which of the following interventions should the nurse include in the plan? -
correct answer-Identify the client's trigger foods.