2023 GRADE A+ SOLUTIONS
A school nurse is assessing a school-age child who experienced the
traumatic loss of a parent 8 months ago. Which of the following
findings should the nurse identify as an indication that the child is
experiencing post-traumatic stress disorder (PTSD)?
Lack of interest in an upcoming holiday
A nurse is caring for a group of clients. Which of the following
findings should the nurse report?
A client who is taking lamotrigine and has developed a rash
A nurse is reviewing laboratory results for a client who has
schizophrenia and is taking clozapine. Which of the following values
should the nurse identify as a contraindication for receiving
clozapine?
WBC count 2,500/mm3 (5,000-10,000/mm3)
A nurse is planning care for a client who has depression and has made
frequent suicide attempts. Which of the following statements
indicates the client has a decreased risk for suicide?
"It is easier to talk about my feelings now."
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?
The client is interested in what the nurse is saying.
A nurse is planning care for a client who has schizophrenia and
reports auditory hallucinations. Which of the following interventions
should the nurse include in the plan?
Promote the use of music to compete with the client's auditory
hallucinations.
A nurse is caring for a client who has impaired cognition.
A nurse is updating the client's plan of care. For each of the
following potential nursing interventions, click to specify if the
potential intervention is anticipated, nonessential, or
contraindicated for the client.
Anticipated- approach from front, give directions to the client,
decrease sensory, assign client to a room
contra- use a vest, ensure the bed is kept, keep the lights off
, non- provide the client with high
A nurse is planning discharge teaching with a family member of a
client who has a new diagnosis of depression. Which of the following
information about relapse should the nurse include?
Early identification of changes, such as decreased social involvement,
is important.
A nurse is establishing a therapeutic relationship with a client who
has antisocial personality disorder. Which of the following
strategies should the nurse use when communicating with this client?
Set realistic limits on the client's behavior.
A nurse in a community health center is teaching families of clients
who have post-traumatic stress disorder (PTSD) about expected
clinical manifestations. Which of the following manifestations should
the nurse include?
Experiences feelings of isolation
A nurse in an inpatient mental health facility is caring for a client.
The client begins pacing with their fists clenched and is verbally
abusing the staff. Which of the following actions should the nurse
take?
Ensure security personnel are available in the background to assist
if the client's behavior escalates.
A nurse is caring for a group of clients. For which of the following
situations should the nurse complete an incident report?
A client was administered one-half of the prescribed dose of
medication.
A nurse in a community health center is working with a group of
clients who have post-traumatic stress disorder. Which of the
following interventions should the nurse include to reduce anxiety
among the group members?
Guided imagery
A nurse in the emergency department is caring for a client who has
alcohol toxicity and is unresponsive. Which of the following
interventions should the nurse take?
Gather supplies for endotracheal intubation.
A nurse is assessing a client who recently used cocaine. Which of the
following findings should the nurse expect?
Hypertension
A client who has a recent diagnosis of bipolar disorder is placed in
a room with a client who has severe depression. The client who has
depression reports to the nurse, "My roommate never sleeps and keeps
me up, too." Which of the following actions should the nurse take?
Move the client who has bipolar disorder to a private room.