,⩥ A nurse is planning care for a client who has depression and has made
frequent suicide attempts. Which of the following statements indicates
the client has a decreased risk for suicide? Answer: "It is easier to talk
about my feelings now."
⩥ A nurse is discussing a 12 steps program with a client who has alcohol
use disorder and is in an acute facility undergoing detoxification. Which
of the following information should the nurse include in the teaching?.
Answer: The client should obtain a sponsor before discharge for an
increased chance of recovery.
⩥ A nurse on a mental health unit observes a client who has acute mania
hit another client. Which of the following actions should the nurse take
first?. Answer: Call for a team of staff members to help with the
situation.
⩥ A nurse in a community health center is working with a group of
clients who have post traumatic stress disorder. Which of the following
interventions should the nurse include to reduce anxiety among the
group members?. Answer: Guided imagery
⩥ A nurse is caring for a newly admitted Client.
For each potential finding, click to specify if the finding is consistent
with positive or negative symptoms of schizophrenia.. Answer:
POSITIVE: Delusions of grandeur, clang associations, catatonia
,NEGATIVE: Algoia, withdrawl from social activities
⩥ A nurse on a mental health unit is caring for a client who has
schizophrenia. After reviewing the client's medical record, the nurse
should notify the provider of which of the following findings?
SELECT THE 5 UNEXPECTED FINDINGS THAT REQUIRE
NOTIFICATION OF THE PROVIDER.. Answer: Temperature
Bowel sounds
ANC level
Myalgia
Heart rate
⩥ A nurse is caring for a client who has a panic disorder.
Click to highlight the findings in the medical record that indicate
maladaptive uses of defense mechanisms.. Answer: Returned from
exercise class in agitated state.
Client tells the nurse, "That exercise instructor was one of my favorite
people here. We had so much in common. But now I know their true
nature. She's evil!"
, ⩥ A nurse is caring for a client who has impaired cognitionA nurse is
updating the client's plan of care. For each of the following potential
nursing interventions, click to specify if the potential intervention is
anticipated, nonessential, or contraindicated for the client:. Answer:
Anticipated:
When addressing the client, approach them from the front when
possible.
Give directions to the client slowly and in a moderate tone of voice.
Decrease sensory stimulation.
Assign the client to a room near the nurses' station.
Nonessential:
Provide the client with high-calorie protein drinks hourly.
Contraindicated:
Use a vest restraint to keep the client in a medical recliner.
Ensure the bed is kept at a working height for the nurse.
Keep the lights off in the client's bedroom and bathroom at night.
⩥ A nurse is admitting a client who has anorexia nervosa and is at 60%
of their ideal body weight. Which of the following interventions should
the nurse include in the plan of care?. Answer: Encourage the client to
drink 125 mL of fluid each hour while awake.
frequent suicide attempts. Which of the following statements indicates
the client has a decreased risk for suicide? Answer: "It is easier to talk
about my feelings now."
⩥ A nurse is discussing a 12 steps program with a client who has alcohol
use disorder and is in an acute facility undergoing detoxification. Which
of the following information should the nurse include in the teaching?.
Answer: The client should obtain a sponsor before discharge for an
increased chance of recovery.
⩥ A nurse on a mental health unit observes a client who has acute mania
hit another client. Which of the following actions should the nurse take
first?. Answer: Call for a team of staff members to help with the
situation.
⩥ A nurse in a community health center is working with a group of
clients who have post traumatic stress disorder. Which of the following
interventions should the nurse include to reduce anxiety among the
group members?. Answer: Guided imagery
⩥ A nurse is caring for a newly admitted Client.
For each potential finding, click to specify if the finding is consistent
with positive or negative symptoms of schizophrenia.. Answer:
POSITIVE: Delusions of grandeur, clang associations, catatonia
,NEGATIVE: Algoia, withdrawl from social activities
⩥ A nurse on a mental health unit is caring for a client who has
schizophrenia. After reviewing the client's medical record, the nurse
should notify the provider of which of the following findings?
SELECT THE 5 UNEXPECTED FINDINGS THAT REQUIRE
NOTIFICATION OF THE PROVIDER.. Answer: Temperature
Bowel sounds
ANC level
Myalgia
Heart rate
⩥ A nurse is caring for a client who has a panic disorder.
Click to highlight the findings in the medical record that indicate
maladaptive uses of defense mechanisms.. Answer: Returned from
exercise class in agitated state.
Client tells the nurse, "That exercise instructor was one of my favorite
people here. We had so much in common. But now I know their true
nature. She's evil!"
, ⩥ A nurse is caring for a client who has impaired cognitionA nurse is
updating the client's plan of care. For each of the following potential
nursing interventions, click to specify if the potential intervention is
anticipated, nonessential, or contraindicated for the client:. Answer:
Anticipated:
When addressing the client, approach them from the front when
possible.
Give directions to the client slowly and in a moderate tone of voice.
Decrease sensory stimulation.
Assign the client to a room near the nurses' station.
Nonessential:
Provide the client with high-calorie protein drinks hourly.
Contraindicated:
Use a vest restraint to keep the client in a medical recliner.
Ensure the bed is kept at a working height for the nurse.
Keep the lights off in the client's bedroom and bathroom at night.
⩥ A nurse is admitting a client who has anorexia nervosa and is at 60%
of their ideal body weight. Which of the following interventions should
the nurse include in the plan of care?. Answer: Encourage the client to
drink 125 mL of fluid each hour while awake.
