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With 82 multiple choices questions and answers
1. A nurse in the emergency room is collecting data from a client who has heroin
intoxication. Which of the following findings should the nurse expect?
A. Seizure activity
B. Respiratory depression
C. Hypersensitivity to pain
D. Increased mental alertness: Respiratory depression
*Heroin is an opioid; therefore, the nurse should expect this client who has heroin
intoxication to exhibit respiratory depression.
2. A nurse on a mental health unit is caring for a client who is displaying signsof anger.
Which of the following pieces of information about the client is the strongest indicator
that the client might become aggressive?
A. The client has marginal coping skills
B. The client has a history of violence
,C. The client feels powerless after being hospitalized
D. The client blames others for her problems: The client has a history of violence
*The client's history of violence is the most important indicator that this client might
become violent; therefore, this is the strongest indicator of potential aggressiveness.
3. A nurse is reinforcing teaching with the caregiver of a client who has dementia.
Which of the following instructions should the nurse include in theteaching?
A. Offer the client a list of activities to choose from
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: Offer finger foods to theclient
*The caregiver should offer finger foods that the client can eat without sitting down. Clients
who have dementia often like to wander and walk off nervous energy, which can decrease
anxiety and calm the client.
4. A nurse is contributing to the plan of care for a client with bipolar disorderwho has
acute mania. Which of the following interventions should the nurserecommend
including in the plan?
A. Provide the client with a low-calorie, low-fat diet
,B. Encourage the client to have frequent rest periods
C. Escort the client to daily group therapy
D. Limit the client's intake of caffeinated beverages to 12 oz per day: Encouragethe client
to have frequent rest periods
*The nurse should recommend encouraging frequent rest periods throughout the day to
decrease the client's risk of exhaustion from the constant activity associatedwith acute
mania.
5. A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of
the following is an effect of using cognitive behavioral therapy (CBT)for a client who has
bipolar disorder?
A. Prevents the need for mood-stabilizing medications
B. Helps the client deal with distorted thought processes
C. Aids in communication among family members
D. Replaces the need for lifestyle interventions: Helps the client deal with distort-ed
thought processes
*CBT assists the client with recognizing distorted thought processes that are mal- adaptive
with regards to recovery.When experiencing mania, the client tends to viewthe future
unrealistically as highly favorable. CBT assists the client in recognizing and challenging
such unrealistic or "automatic" thoughts and can help the client andthe health care team
recognize early trends toward mania
6. A nurse is caring for a client in a mental health facility and overhears
, the client discussing plans to harm her father-in-law physically when she is
discharged. Which of the following interventions should the nurse take?
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 confidential
D. Place the client in individual observation: Notify the provider of the client'sthreat
*It is the nurse's duty to notify the provider of the client's threat. It will then be the
provider's responsibility to warn the the intended victim or the police of the client'sthreat
7. A nurse is preparing to meet with a client who has borderline personality disorder.
Which of the following actions should the nurse plan to take duringthe working phase
of the therapeutic relationship?