1. A client with bipolar disorder who is prescribed lithium is receiving teaching regarding this medication and is
preparing to be discharged from the mental health facility. The nurse determines that the teaching was
effective when the client states that which of the following is a manifestation of lithium toxicity?
A. Vomiting and diarrhea
Rationale: mLithium mis ma mmedication mused mto mtreat mbipolar mdisorder. mEarly mmanifestations mof
mtoxicity minclude mdiarrhea, mlethargy, mimpaired mcoordination, mmuscle mweakness,
mnausea mor mvomiting, mslurred mspeech, mand mtrembling. mIf mthe mclient mexperiences
mvomiting mand mdiarrhea, mthe mclient mshould momit mthe mnext mdose mof mlithium mand
mcall mthe mprovider.
B. Increased mflatulence
Rationale: m Increased mflatulence mis ma mcommon mside meffect mof mlithium, mbut mit mis mnot ma msign
m of mlithium mtoxicity.
C. Loss mof mappetite
Rationale: m Loss mof mappetite mis ma mcommon mside meffect mof mlithium, mespecially mduring mthe
m body's madjustment mto mthe mmedication, mbut mit mis mnot ma msign mof mlithium mtoxicity.
D. Increased murination
Rationale: mIncreased murination mis ma mcommon mside meffect, mbut mit mis mnot ma msign mof mlithium
mtoxicity. mClients mwho mexperience mthis mside meffect mshould mbe minstructed mto
mincrease mfluid mintake mto mprevent mdehydration.
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,2. A mnurse mis mcaring mfor ma mclient mhospitalized mfor mtreatment mof msevere mdepression. mWhich mof mthe mfollowing
mstrategies mshould mthe mnurse mplan mto mcontribute mto mthe mclient's mplan mof mcare?
A. Giving mthe mclient mchoices mof mactivities
Rationale: mThis mis mnot man mappropriate mnursing mapproach mto minclude min mthis mclient's mplan mof
mcare.
Making mchoices mis mdifficult mfor ma mclient mwho mhas mdepression.
B. Spending mtime mwith mthe mclient
Rationale: mThis moption muses mthe mtherapeutic mcommunication mtool mof mbeing msilent.
mDepression malso minvolves mdiminished mself-esteem, mand mspending mtime mwith mthe
mclient mconveys mthat mhe mis mworth mthe mnurse's mtime mand mattention.
C. Playing ma mgame mof mchess mwith mthe mclient
Rationale: m An mintellectual mgame mthat mrequires mmaking mchoices mand mdecisions, msuch mas
m chess, mwould mnot mbe ma mgood mactivity mfor ma mdepressed mclient.
D. Encouraging mdecision mmaking
Rationale: m This mis mnot man mappropriate mnursing mapproach mto minclude min mthis mclient's mplan mof
mcare.
Decision mmaking mis mdifficult mfor ma mdepressed mclient.
3. The mparents mof ma m4-year-old mchild mwho mhas ma mserious mchronic millness mtell mthe mnurse mthat mthey mhave
mtaken mtheir mson’ ms mname moff mthe mlist mfor mlittle mleague mbaseball mnext mseason. mWhich mof mthe mfollowing mis
man mappropriate mnursing mresponse mto mthe mparents?
A. “It mmust mbe mfrustrating mfor myou mto mhave mto mcancel man mactivity myour mson menjoyed.”
Rationale: mThis mresponse mdemonstrates mthe mtherapeutic mcommunication mtechnique mof
msharing mempathy. mIt mis mneutral mand mnonjudgmental mand minvites mfurther
mcommunication mand msharing.
B. “Baseball mcan mbe ma mdangerous msport mfor mchildren.”
Rationale: m This mresponse mis mstereotypical mand mfails mto mconvey mempathy mand munderstanding.
C. “You mnever mknow. mHe mcould mbe mready mfor mbaseball mby mthe mspring.”
Rationale: m With mthis mresponse, mthe mnurse mgives mthe mparents mfalse mreassurance, mwhich mis
ma mnontherapeutic mcommunication mtechnique.
D. “I’m mso msorry mthat myou mfelt myou mhad mto mdo mthat.”
Rationale: mThis mresponse millustrates mthe mnontherapeutic mcommunication mtechnique mof
moffering msympathy. mAlthough mit mshows mcompassion, mit malso mdemonstrates mpity
mor msubjectivity mrather mthan mthe mobjectivity mthat mcan mtruly mhelp msolve ma
mproblem mor moffer msupport.
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, 4. A mnurse mis mtalking mwith ma mclient mwho mhas mschizophrenia. mSuddenly mthe mclient mstates, m“I’m mfrightened. mDo
myou mhear mthat? mThe mvoices mare mtelling mme mto mdo mterrible mthings.” mWhich mof mthe mfollowing mresponses
mby mthe mnurse mis mappropriate?
A. “You mneed mto mtell mthe mvoices mto mleave myou malone.”
Rationale: mThis mstatement macknowledges mthe mreality mof mthe mvoices mand mencourages mthe
mclient mto margue mwith mthe mvoices, mboth mof mwhich mare mnontherapeutic mapproaches
mfor mcommunication mwith ma mclient mwho mis mexperiencing ma mhallucination.
B. “There mare mno mvoices.”
Rationale: mNegating mthe mclient’s mperception mof mthe mhallucination mis ma mnontherapeutic
mapproach mfor mcommunication mwith ma mclient mwho mis mexperiencing ma
mhallucination.
C. “What mare mthe mvoices mtelling myou mto mdo?”
Rationale: mThis mstatement mrecognizes mthe mrisk minvolved mwith ma mcommand mhallucination
mand masks mthe mclient mdirectly mabout mthe mhallucination. mThis mis ma mtherapeutic
mapproach mto mcommunicating mwith ma mclient mwho mis mexperiencing ma mhallucination.
D. “Why mdo myou mthink myou mare mhearing mthe mvoices?”
Rationale: m Asking ma m“why” mquestion mis mnontherapeutic mand mincreases mthe mdefensiveness
m of ma mclient mexperiencing ma mhallucination.
5. A mnurse mis mcaring mfor ma mclient mwho mhas mobsessive-compulsive mdisorder. mThe mclient mhas ma mfull mset mof
mdentures mbecause mhe meroded mall mhis mtooth menamel mwith mhis mbrushing mrituals. mHe malso mbrushes mhis
mtongue mseveral mtimes ma mday mand mhas mdeveloped mseveral mulcerations. mIn mplanning m the mclient's mcare,
mencouraging mwhich mof mthe mfollowing mshould mbe mthe minitial mpriority?
A. Establishing mappropriate moral mhygiene mroutines
Rationale: mRestoring mphysiological mintegrity mis mthe mhighest minitial mpriority mfor mthis mclient.
mThis mwill mbe mdone mwhile mworking mon mthe mlong-term mgoal mof mdecreasing mthe
mmouth mcare mrituals.
B. Verbalizing mthe mcauses mof mhis mritualistic mbehavior
Rationale: m This mis mnot mthe mhighest mpriority.
C. Ensuring mthat mthe mclient mrelies mon mthe mnurse mwhen mhe mis mfeeling manxious
Rationale: m This mis mnot mthe mhighest mpriority.
D. Minimizing mthe mclient's mexcessive mmouth mcare mrituals
Rationale: m This mis mnot mthe mhighest mpriority.
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preparing to be discharged from the mental health facility. The nurse determines that the teaching was
effective when the client states that which of the following is a manifestation of lithium toxicity?
A. Vomiting and diarrhea
Rationale: mLithium mis ma mmedication mused mto mtreat mbipolar mdisorder. mEarly mmanifestations mof
mtoxicity minclude mdiarrhea, mlethargy, mimpaired mcoordination, mmuscle mweakness,
mnausea mor mvomiting, mslurred mspeech, mand mtrembling. mIf mthe mclient mexperiences
mvomiting mand mdiarrhea, mthe mclient mshould momit mthe mnext mdose mof mlithium mand
mcall mthe mprovider.
B. Increased mflatulence
Rationale: m Increased mflatulence mis ma mcommon mside meffect mof mlithium, mbut mit mis mnot ma msign
m of mlithium mtoxicity.
C. Loss mof mappetite
Rationale: m Loss mof mappetite mis ma mcommon mside meffect mof mlithium, mespecially mduring mthe
m body's madjustment mto mthe mmedication, mbut mit mis mnot ma msign mof mlithium mtoxicity.
D. Increased murination
Rationale: mIncreased murination mis ma mcommon mside meffect, mbut mit mis mnot ma msign mof mlithium
mtoxicity. mClients mwho mexperience mthis mside meffect mshould mbe minstructed mto
mincrease mfluid mintake mto mprevent mdehydration.
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m16
,2. A mnurse mis mcaring mfor ma mclient mhospitalized mfor mtreatment mof msevere mdepression. mWhich mof mthe mfollowing
mstrategies mshould mthe mnurse mplan mto mcontribute mto mthe mclient's mplan mof mcare?
A. Giving mthe mclient mchoices mof mactivities
Rationale: mThis mis mnot man mappropriate mnursing mapproach mto minclude min mthis mclient's mplan mof
mcare.
Making mchoices mis mdifficult mfor ma mclient mwho mhas mdepression.
B. Spending mtime mwith mthe mclient
Rationale: mThis moption muses mthe mtherapeutic mcommunication mtool mof mbeing msilent.
mDepression malso minvolves mdiminished mself-esteem, mand mspending mtime mwith mthe
mclient mconveys mthat mhe mis mworth mthe mnurse's mtime mand mattention.
C. Playing ma mgame mof mchess mwith mthe mclient
Rationale: m An mintellectual mgame mthat mrequires mmaking mchoices mand mdecisions, msuch mas
m chess, mwould mnot mbe ma mgood mactivity mfor ma mdepressed mclient.
D. Encouraging mdecision mmaking
Rationale: m This mis mnot man mappropriate mnursing mapproach mto minclude min mthis mclient's mplan mof
mcare.
Decision mmaking mis mdifficult mfor ma mdepressed mclient.
3. The mparents mof ma m4-year-old mchild mwho mhas ma mserious mchronic millness mtell mthe mnurse mthat mthey mhave
mtaken mtheir mson’ ms mname moff mthe mlist mfor mlittle mleague mbaseball mnext mseason. mWhich mof mthe mfollowing mis
man mappropriate mnursing mresponse mto mthe mparents?
A. “It mmust mbe mfrustrating mfor myou mto mhave mto mcancel man mactivity myour mson menjoyed.”
Rationale: mThis mresponse mdemonstrates mthe mtherapeutic mcommunication mtechnique mof
msharing mempathy. mIt mis mneutral mand mnonjudgmental mand minvites mfurther
mcommunication mand msharing.
B. “Baseball mcan mbe ma mdangerous msport mfor mchildren.”
Rationale: m This mresponse mis mstereotypical mand mfails mto mconvey mempathy mand munderstanding.
C. “You mnever mknow. mHe mcould mbe mready mfor mbaseball mby mthe mspring.”
Rationale: m With mthis mresponse, mthe mnurse mgives mthe mparents mfalse mreassurance, mwhich mis
ma mnontherapeutic mcommunication mtechnique.
D. “I’m mso msorry mthat myou mfelt myou mhad mto mdo mthat.”
Rationale: mThis mresponse millustrates mthe mnontherapeutic mcommunication mtechnique mof
moffering msympathy. mAlthough mit mshows mcompassion, mit malso mdemonstrates mpity
mor msubjectivity mrather mthan mthe mobjectivity mthat mcan mtruly mhelp msolve ma
mproblem mor moffer msupport.
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, 4. A mnurse mis mtalking mwith ma mclient mwho mhas mschizophrenia. mSuddenly mthe mclient mstates, m“I’m mfrightened. mDo
myou mhear mthat? mThe mvoices mare mtelling mme mto mdo mterrible mthings.” mWhich mof mthe mfollowing mresponses
mby mthe mnurse mis mappropriate?
A. “You mneed mto mtell mthe mvoices mto mleave myou malone.”
Rationale: mThis mstatement macknowledges mthe mreality mof mthe mvoices mand mencourages mthe
mclient mto margue mwith mthe mvoices, mboth mof mwhich mare mnontherapeutic mapproaches
mfor mcommunication mwith ma mclient mwho mis mexperiencing ma mhallucination.
B. “There mare mno mvoices.”
Rationale: mNegating mthe mclient’s mperception mof mthe mhallucination mis ma mnontherapeutic
mapproach mfor mcommunication mwith ma mclient mwho mis mexperiencing ma
mhallucination.
C. “What mare mthe mvoices mtelling myou mto mdo?”
Rationale: mThis mstatement mrecognizes mthe mrisk minvolved mwith ma mcommand mhallucination
mand masks mthe mclient mdirectly mabout mthe mhallucination. mThis mis ma mtherapeutic
mapproach mto mcommunicating mwith ma mclient mwho mis mexperiencing ma mhallucination.
D. “Why mdo myou mthink myou mare mhearing mthe mvoices?”
Rationale: m Asking ma m“why” mquestion mis mnontherapeutic mand mincreases mthe mdefensiveness
m of ma mclient mexperiencing ma mhallucination.
5. A mnurse mis mcaring mfor ma mclient mwho mhas mobsessive-compulsive mdisorder. mThe mclient mhas ma mfull mset mof
mdentures mbecause mhe meroded mall mhis mtooth menamel mwith mhis mbrushing mrituals. mHe malso mbrushes mhis
mtongue mseveral mtimes ma mday mand mhas mdeveloped mseveral mulcerations. mIn mplanning m the mclient's mcare,
mencouraging mwhich mof mthe mfollowing mshould mbe mthe minitial mpriority?
A. Establishing mappropriate moral mhygiene mroutines
Rationale: mRestoring mphysiological mintegrity mis mthe mhighest minitial mpriority mfor mthis mclient.
mThis mwill mbe mdone mwhile mworking mon mthe mlong-term mgoal mof mdecreasing mthe
mmouth mcare mrituals.
B. Verbalizing mthe mcauses mof mhis mritualistic mbehavior
Rationale: m This mis mnot mthe mhighest mpriority.
C. Ensuring mthat mthe mclient mrelies mon mthe mnurse mwhen mhe mis mfeeling manxious
Rationale: m This mis mnot mthe mhighest mpriority.
D. Minimizing mthe mclient's mexcessive mmouth mcare mrituals
Rationale: m This mis mnot mthe mhighest mpriority.
page m3 mof
m16
