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1. A nurse in a mental health clinic is caring for a client Correct = 3. Hand Tremors
who has bipolar disorder and reports that they
stopped taking lithium 2 weeks ago. The nurse - Fine hand tremors are an ex-
should recognize which of the following as an ex- pected adverse effect of lithi-
pected adverse effect that might have caused the um and can interfere with per-
client to spot taking the medication? formance of ADLs, causing the
client to stop taking the medica-
1. Sore throat tion.
2. Photophobia
3. Hand tremors *Diarrhea is an early manifesta-
4. Constipation tion of lithium toxicity
2. A nurse is updating the plan of care for a client who Correct = 2. Identify the client's
has bulimia nervosa and is 5% above their ideal trigger foods.
body weight. Which of the following interventions
should the nurse include in the plan? - The nurse should identify the
trigger foods that initiate the
1. Include a liquid supplement with meals. client's binge and assist the
2. Identify the client's trigger foods. client to understanding their
3. Allow the client at least 1 hr for each meal. thoughts and behavior that re-
4. Weigh the client at bedtime each day. late to the food.
The nurse should limit the
client's meal times to about 30
min to prevent putting excessive
focus on food.
The nurse should weigh the
client immediately after they
wake up and void and prior to
oral intake. The nurse should
weigh the client daily for the first
week and then three times per
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week.
*The nurse should include a liq-
uid supplement for a client who
is below their ideal body weight
and might not be able to eat
solid foods at first or might need
the additional nutrition to gain
weight.
3. A nurse is caring for a client whose child has Correct = 4. "It is not uncommon
a terminal illness. The client requests informa- to feel angry toward yourself or
tion about how to deal with the upcoming loss. others."
Which of the following statements should the
nurse make? - Feelings of blame and anger
toward oneself or others are an
1. "It will be better for you to keep busy to avoid expected reaction when a client
thinking about your child's death." is experiencing a loss.
2. "You will complete the grieving process about a
year after your child's death." The grief process has no time-
3. "The grief process will start once your child actu- line. It varies for each individ-
ally dies." ual.
4. "It is not uncommon to feel angry toward your- The client can begin anticipato-
self or others." ry grieving during the child's ill-
ness.
4. A nurse in a mental health clinic is planning care for Correct = 4. Instruct the client to
a client who has a new prescription for olanzapine. avoid driving during initial ther-
Which of the following interventions should the apy.
nurse identify as the priority?
- The greatest risk to this client
1. Advise the client to take frequent sips of water. is injury resulting from drowsi-
2. Recommend that the client exercise regularly. ness or dizziness. Therefore, the
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3. Consult a dietitian for a calorie-controlled diet nurse's priority intervention is to
plan. instruct the client to avoid activ-
4. Instruct the client to avoid driving during initial ities that require mental alert-
therapy. ness during initial medication
therapy.
The nurse should advise the
client to take frequent sips of
water due to the adverse effect
of dry mouth. However, this is
not the nurse's priority interven-
tion.
The nurse should advise the
client to exercise regularly due
to the adverse effects of weight
gain and constipation. However,
this is not the nurse's priority in-
tervention.
The nurse should consult a di-
etitian for a calorie-controlled
diet plan due to the adverse ef-
fect of weight gain. However,
this is not the nurse's priority in-
tervention.
5. A nurse is counseling an adolescent who has Correct = 2. "You're saying that
anorexia nervosa and reports excessive laxative you think you are fat and are
use and fear of gaining weight. The Client states, using laxatives because you are
"I'm so fat I can't even stand to look at my- afraid of gaining weight."
self.". Which of the following therapeutic respons-
es demonstrates the nurse's use of summarizing? - The nurse is using the thera-
peutic technique of summariz-
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1. "You've discussed several concerns about your ing to review the key points of
weight. Let's go back and talk about your belief that the discussion.
you are fat."
2. "You're saying that you think you are fat and are
using laxatives because you are afraid of gaining
weight."
3. "You don't want to look at yourself because you
think you are fat."
4. "You and I can work together to overcome your
fears of gaining weight."
6. A nurse is admitting a client who has schizophrenia Correct = 1. Clang Association
to an acute care setting. When the nurse questions
the client regarding their admission, the client - The nurse should document
states, "I'm red, in the head, and I'm going to bed!". that the client's speech uses
The nurse should document the client's speech clang associations, which often
pattern as which of the following? rhyme or contain a string of
words that can have a similar
1. Clang Association sound.
2. Word Salad
3. Neologism
4. Echolalia
7. NGN: A nurse is caring for a Client who has an Correct =
alcohol use disorder.
Dropdown 1:
Complete the following sentence by using the list 2. Violent Behavior
of options... - The greatest risk for the client
is engaging in violent behavior
Dropdown 1: "The Client is at greatest risk for due to the withdrawal of alcohol,
________ which is causing them increas-
1. Dehydration ing agitation. The nurse should
2. Violent Behavior