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1. A nurse is caring for a client who has a history of substance use disorder and was
involuntarily admitted to a mental health facility. When the nurse at- tempts to administer oral
lorazepam, the client refuses to take the medicationand becomes physically aggressive. Which
of the following actions should thenurse take?
A. Do not administer the lorazepam
,B. Request a prescription for IV lorazepam
C. Request that another nurse attempt to administer the lorazepam
D. Place the lorazepam in the client's for
.
.: Ans>> A. Do not administer the lorazepam.
Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment.
Therefore, the nurse should hold the medication and document the client'srefusal.
2. A nurse is planning care for a client who has depression and has made frequent
suicide attempts. Which of the following statements indicates theclient has a decreased
risk for suicide?
A. "I'm relived now that my financial affairs are in order."
B. "It is easier to talk about my feelings now."
C. "Suddenly I have enough energy to do anything I want."
D. "Thank you for always taking such good care of me."
.
.:Ans>> B. "It is easier to talkabout my feelings now."
When clients express their feelings, this indicates a positive treatment outcome.
3. 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 thefollowing statements
should the nurse make?
A. "It will be better for you to keep busy to avoid thinking about your child'sdeath."
B. "You will complete the grieving process about a year after your child'sdeath."
C. "The grief process will start once your child actually dies."
D. "It is not uncommon to feel angry toward yourself or others."
.
.: Ans>> D. "It is notuncommon to feel angry toward yourself or others."
Feelings of blame and anger towards oneself or others are an expected reactionwhen a client is
experiencing a loss.
4. During a client's initial interview in a mental health inpatient setting, a nurse identifies that
the client is maintaining eye contact and leaning forward. Which of the following assumptions
should the nurse make based on the client's
, nonverbal behaviors?
A. The client is interested in what the nurse is saying
B. The client is attempting to manipulate the nurse
C. The client is physically attracted to the nurse
D. The client needs to feel accepted by the nurse
.
.: Ans>> A. The client is interested inwhat the nurse is saying.
The client's posture and eye contact demonstrates an interest in the interview andwhat the nurse is
saying.
5. A nurse is reviewing the electronic medical record of a client who has schizophrenia and
is taking clozapine. Which of the following findings is thepriority for the nurse to notify the
provider?
A. The client's chart indicates a 1.36 kg (3 lb.) weight gain in 1 month.
B. The client reports an inability to breathe easily.
C. The client's laboratory results indicate a fasting blood glucose level of 130mg/dL.
D. The client reports having recently started smoking cigarettes.
.
.: Ans>> B. The clientreports an inability to breathe easily.