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The nurse is caring for an adult male client with catatonic schizophrenia who is
mute and motionless. Which is the priority nursing problem?
Impaired mobility.
Ineffective individual coping.
Impaired verbal communication.
High risk for fluid and electrolyte imbalance. - 🧠ANSWER ✔✔High risk for fluid
and electrolyte imbalance.
A young adult female client with panic disorder arrives in the Emergency Center
with a 4-day history of chest pain that began when her boyfriend left her. Initial
assessment reveals normal cardiopulmonary findings. Which information is most
important for the nurse to obtain?
Drugs taken in last 7 days.
Family history of suicide.
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,Usual coping mechanisms.
Frequency of anxiety attacks. - 🧠ANSWER ✔✔Drugs taken in last 7 days.
A male client is brought to the emergency department by a police officer, who
reports that the client was "disturbing the peace" by running naked in the street,
striking out at others, and smashing car windows. Which behaviors should the
client demonstrate to determine if he should be evaluated for involuntary
commitment? (Choose all that apply.)
Select all that apply
Threats to kill his friend.
Disruptive behaviors in a community setting.
Hears voices telling him to kill himself.
Reports he has not needed a bath in 4 months.
Created extensive private property damage.
Says he has not eaten in 3 days. - 🧠ANSWER ✔✔Threats to kill his friend, Hears
voices telling him to kill himself, Reports he has not needed a bath in 4 months,
Says he has not eaten in 3 days.
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,Which action is most important for the nurse to implement during the initial
interview for a client who is admitted to the mental health unit?
Establish rapport in each phase of the nurse-client relationship.
Determine the client's ability to communicate effectively.
Reflect on previous psychiatric interviews the nurse has performed.
Ensure data is collected and recorded in a systematic sequence. - 🧠ANSWER
✔✔Establish rapport in each phase of the nurse-client relationship.
During the admission of a male client to the mental health unit, the client tells the
nurse that he had a panic attack today and ran out of the physician's office. Which
question is most important for the nurse to ask this client?
On a scale of 1 to 10 how do you rate your anxiety level?
How would you describe your mood right now?
Have you had any thoughts of hurting yourself?
What medications have you taken in the last 24 hours? - 🧠ANSWER ✔✔Have you
had any thoughts of hurting yourself?
Which action should the nurse implement first for a client experiencing alcohol
withdrawal?
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, Apply vest or extremity restraints.
Give an alpha-adrenergic blocker.
Provide a diet high in protein and calories.
Prepare the environment to prevent self-injury. - 🧠ANSWER ✔✔Prepare the
environment to prevent self-injury.
An older client is admitted to a psychiatric hospital with the diagnosis, "Major
depression, single episode." Which laboratory value is most important for the nurse
to report to the healthcare provider immediately?
Increased serum creatinine level.
Positive rapid plasma reagin (RPR).
Increased thyroid stimulating hormone (TSH).
Elevated serum calcium level. - 🧠ANSWER ✔✔Increased thyroid stimulating
hormone (TSH).
While assessing an older male client, a nurse working in the outpatient clinic
notices bruises on the client's chest. The client admits that his daughter, who is his
caregiver, becomes frustrated and sometimes hits him. Which is the priority
outcome for the client who is experiencing physical abuse at home?
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