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a 35 year old male client who has been hospitalized for 2 weeks
for chronic paranoia continues to state that someone is trying to
steal his clothing. which action should the nurse implement?
Correct Answer encourage the client to actively participate in
assigned activities on the unit
a 35 year old male on the psychiatric ward of a general hospital
believes that someone is trying to poison him. the nurse
understands that a client's delusions are most likely related to his
Correct Answer low self esteem
a 65 year old female client complains to the nurse that recently
she has been hearing voices. what question should the nurse ask
this client first? Correct Answer "are you ever alone when you
hear the voices?"
a child is brought to the ER with a broken arm. because of the
other injuries, the nurse suspects the child may be a victim of
abuse. when the nurse tries to give the son an injection, the
child's mother becomes very loud and shouts, "I won't leave my
son! Don't you touch him! You'll hurt my child!" what is the
best interpretation of the mother's statements? the mother is
Correct Answer projecting her feelings onto the nurse
A client diagnosed with schizophrenia looks frightened and tells
the nurse, "I keep hearing the voices telling me to hurt
,somebody. Don't you hear them?" Which response is best for the
nurse to provide? Correct Answer I don't hear the voices, but
you seem very frightened.
A client is admitted to the mental health unit and reports taking
extra antianxiety medication because "I am so stressed out. I just
wanted to go to sleep." The nurse should plan one on one
observation of the client based on which statement? Correct
Answer I don't want to talk. Nothing matters anymore
A client is admitted with a closed head injury after a fall, has a
blood alcohol level of 0.28 (28%), and is difficult to arouse.
Which intervention during the first 6 hours following admission
should the RN identify as the priority? Correct Answer Place in
a side lying position with head of bed elevated
a client is admitted with a diagnosis of depression. the nurse
knows that which characteristic is most indicative of depression?
Correct Answer a negative view of self and the future
A client is discussing feeling related to a recent loss with the
nurse. The nurse remains silent when the client says, "I don't
know how I will go on." What is the most likely reason for the
nurse's behavior? Correct Answer Silence allows the client to
reflect on what was said
A client is prescribed risperidone (Risperdal) for schizophrenia.
Which side effects should the nurse report to the healthcare
provider? Correct Answer
a client is receiving substitution therapy during withdrawal from
benzodiazepines. which expected outcome statement has the
, highest priority when planning nursing care? Correct Answer
excessive CNS stimulation will be reduced
A client is receiving substitution therapy during withdrawal
from benzodiazepines. Which expected outcome statement has
the highest priority when planning nursing care? Correct
Answer excessive CNS stimulation will be reduced
A client on the mental health unit is becoming more agitated,
shouting at the staff, and pacing in the hallway. When the PRN
medication is offered, the client refuses the medication and
defiantly sits on the floor in the middle of the unit hallway.
What nursing intervention should the RN implement first?
Correct Answer Take other clients in the area to the client
lounge
A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the nurse is reinforcing
the process. Which intervention has the highest priority for this
client's plan of care? Correct Answer Establish trust by
providing a calm, safe environment
A client who is admitted to the mental health unit reports SOB
and dizziness. The client tells the nurse, "I feel like I'm going to
die." Which nursing problem should the nurse include in this
client's plan of care? Correct Answer Moderate anxiety
a client who is being treated with lithium carbonate for bipolar
disorder develops diarrhea, vomiting, and drowsiness. what
action should the nurse take? Correct Answer notify the HCP
of the symptoms prior to the next administration of the drug