Questions and Answers
a nurse is caring for an older adult client who has dementia and has wandered into
the day room looking for their deceased partner. which of the following actions
should the nurse take? - Answer-talk with the client about activities they enjoyed with
their partner
a nurse is documenting admission assessment findings for a client who has major
depressive disorder. the nurse should identify which of the following findings as
clinical manifestations? - Answer--feelings of hopelessness
-anhedonia
-flat facial expression
a nurse is admitting a client who has alcohol use disorder. which of the following
statements by the client indicates that the client is using denial as a defense
mechanism? - Answer-"I am able to go to work every day, so I don't have a
problem."
a nurse is admitting a client who has anorexia nervosa and is at 60% of 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.
a nurse is caring for a client who has schizophrenia and is experiencing psychosis.
the nurse should identify that which of the following findings indicates a potential
psychiatric emergency? - Answer-the client reports command hallucinations
a client who has paranoid schizophrenia is attending a treatment planning
conference with a family member. during the discussion of the medication adherence
portion of the plan, a nurse notices that the family member seems distracted. which
of the following actions should the nurse take? - Answer-ask the family member if
they have any thoughts or questions about the treatment plan
a nurse is planning care for an adolescent who is being admitted to an acute care
unit following a suicide attempt. which of the following interventions should the nurse
identify as the priority? - Answer-arrange one-to-one observation of the client
a nurse is caring for a group of clients. which of the following findings should the
nurse report? - Answer-a client who is taking lamotrigine and has developed a rash
a nurse is planning care for a client who is experiencing acute mania. which of the
following interventions should the nurse include in the plan to promote sleep? -
Answer-encourage frequent rest periods throughout the day
a nurse is reviewing routine lab values for several clients who are taking lithium
carbonate. which of the following clients should the nurse assess further for findings
indicating lithium toxicity? - Answer-a client who has a sodium level of 128 mEq/L
, a nurse is discussing the home care of a client who has advanced Alzheimer's
disease with the client's partner, who is planning to go out of town for several days.
which of the following resources should the nurse recommend to the caregiver? -
Answer-respite care
a home health nurse is assessing an older adult client whose sibling is the primary
caregiver. which of the following findings should the nurse identify as a possible
indicator of neglect? - Answer-inappropriate dress
a community health nurse is planning an education program about depressive
disorders. which of the following factors should the nurse include as increasing the
risk for depression? - Answer-substance use disorder
a nurse is admitting a female client who has anorexia nervosa. which of the following
manifestations should the nurse expect during the admission assessment? - Answer-
orthostatic hypotension
a nurse is caring for a client whose child has a terminal illness. the client requests
information about how to deal with the upcoming loss. which of the following
statements should the nurse make? - Answer-"it is not uncommon to feel angry
toward yourself or others."
a nurse on a mental health unit is caring for a recently admitted client.
exhibit 1: 0800 - BP: 110/78, HR: 76/min, RR: 18/min, Temp: 98.6; 1200 - BP:
116/80, HR: 88/min, RR: 20/min, temp: 100.4
exhibit 2: 22 year old client admitted following episodes of hallucinations and
delusions. outpatient treatment has been ineffective. client has been unable to
maintain a job and friends have said the client has been acting different than usual.
family members have noticed that the client no longer maintains a clean and neat
appearance - Answer-positive symptoms: delusions of grandeur, clang associations,
catatonia
negative symptoms: absence of intonation in speech, alogia, and withdrawal from
social activities
a nurse in a community health center is counseling a family of two parents and two
children. which of the following statements by a family members indicates
manipulative behavior? - Answer-"if you do my homework for me, I won't bother you
for the rest of the day."
a nurse is caring for a client who has antisocial personality disorder and is receiving
behavioral therapy through operant conditioning. which of the following client
behaviors indicates effectiveness of the therapy? - Answer-refrains from
manipulating others to earn dining room privileges
a nurse is planning discharge for a client who has bipolar disorder and has a
prescription for lithium. which of the following client statements indicates
understanding of the teaching about the medication? - Answer-"I should eat a regular
diet with normal amounts of salt and fluids."