Real Actual Question And Answers with Rationales(Rated A+)
A nurse is assisting with obtaining consent for a client who has
been declared legally incompetent. Which of the following actions
should the nurse take?
a. Ask the charge nurse to obtain informed consent
b. Contact the facility social worker to obtain consent
c. Request that the clients guardian sign the consent
d. Explain implied consent to the client's family: C.
2. A nurse is assessing a client who has delirium. Which of the following
things requires immediate intervention by the nurse?
a. Rapid mood swings
b. Command hallucinations
c. Impaired memory
d. Inappropriate speech patterns: A.
,3. A nurse is reviewing the medication administration record of a client
who has major
depressive disorder and a new prescription for selegiline. The nurse should
recognize that which of the following client medications is contraindicated
when taken with selegiline?
a. Warfarin
b. Fluoxetine
c. Calcium carbonate
d. Acetaminophen: B.
4. A nurse in a long-term care facility is assessing a client who has
dementia. Which of the following findings should the nurse identify as a
risk for this client?
a. Outside doors have locks
b. The bed is in the low position on
c. Hallways are long distances
d. The room has an area rug: D.
5. A nurse is providing behavioral therapy for a client who has obsessive-
compulsive disorder.
,The client repeatedly checks that the doors are locked at night. Which of the
following
instructions should the nurse give the client when using a thought-stopping
technique? Pick 2.
a. "Ask a family member to check the locks for you at night"
b. "Keep a journal of how often you check the locks each night
c. "Snap a rubber band on your wrist when you think about checking
the locks
d. Focus on abdominal breathing whenever you go to check the locks":
C. D..
6. A nurse is providing teaching about relapse prevention to a client
who has schizophrenia.
Which of the following statements by the client indicates an understanding
of the teaching?
a. I should avoid being around others if I think I having a relapse
b. I should let my counselor know if I am having trouble sleeping
c. I shouldn't worry about the voices because they are a part of my illness
, d. I should increase my carbohydrate intake to maintain my energy level: B.
7. A nurse is assessing a client for negative manifestations of
schizophrenia. Which of the following findings should the nurse
expect?
a. Echopraxia
b. Delusions
c. Anergia
d. Tangentiality: C.
8. A nurse is preparing for an interprofessional team meeting regarding
a newly admitted
client who has a major depressive disorder. Which of the following
findings obtained during the initial assessment is the priority to report to
other disciplines?
a. Poor problem-solving skills
b. Markedly neglected hygiene
c. Significant weight loss
d. Psychomotor retardation: D.
9. A nurse is caring for a school-age child who has a fractured arm. The