100 QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|ALREADY GRADED A+||BRAND
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A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and
will receive succinylcholine. The client asks the nurse about this medication. Which
of the following responses should the nurse make? - ANSWER: "Succinylcholine is
given to reduce muscle movements during therapy." - Succinylcholine is a muscle-
paralyzing agent that will decrease muscle movement during the procedure so the
client is less likely to be injured.
A nurse is discussing the home care of a client who has advanced Alzheimer's disease
with the client's partner, who is planning to go out of town for several days. Which
of the following resources should the nurse recommend to the caregiver? - ANSWER:
Respite care
A nurse is reviewing the electronic medical record of a client who has schizophrenia
and is taking clozapine. Which of the following findings is the priority for the nurse to
notify the provider? - ANSWER: The client reports an inability to breathe easily.
A nurse is caring for a client who has schizophrenia and began taking a conventional
antipsychotic medication yesterday. Which of the following findings indicates the
nurse should administer benztropine 2 mg IM? - ANSWER: Shuffling gait
A nurse is caring for a client who has antisocial personality disorder and is receiving
behavioral therapy through operant conditioning. Which of the following client
behaviors indicates effectiveness of the therapy? - ANSWER: Refrains from
manipulating others to earn dining room privileges
A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body
weight. Which of the following interventions should the nurse include in the plan of
care? - ANSWER: Encourage the client to drink 125 mL of fluid each hour while
awake.
A nurse is obtaining a mental health history from an older adult client. Which of the
following actions should the nurse plan to take? - ANSWER: Interview the client in a
private setting.
A community health nurse is planning an education program about depressive
disorders. Which of the following factors should the nurse include as increasing the
risk for depression? - ANSWER: Substance use disorder
A nurse is admitting a client who has alcohol use disorder. Which of the following
statements by the client indicates that the client is using denial as a defense
,mechanism? - ANSWER: "I am able to go to work every day, so I don't have a
problem."
A client who has paranoid schizophrenia is attending a treatment planning
conference with a family member. During the discussion of the medication
adherence portion of the plan, a nurse notices that the family member seems
distracted. Which of the following actions should the nurse take? - ANSWER: Ask the
family member if they have any thoughts or questions about the treatment plan.
A nurse is documenting admission assessment findings for a client who has major
depressive disorder. The nurse should identify which of the following findings as
clinical manifestations? (Select all that apply.) - ANSWER: Feelings of hopelessness
Anhedonia
Flat facial expression
A nurse is reviewing routine laboratory values for several clients who are taking
lithium carbonate. Which of the following clients should the nurse assess further for
flings indicating lithium toxicity? - ANSWER: A client who has a sodium level of 128
mEq/L
A nurse is assessing a client who recently used cocaine. Which of the following
findings should the nurse expect? - ANSWER: Hypertension
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? - ANSWER: Promote the use of music to compete with the client's auditory
hallucinations.
A client who has a diagnosis of depression is attending group therapy. During the
group meeting, the nurse asks each member to identify one goal for the day. When it
is the client's turn, they do not respond. Which of the following actions should the
nurse take before repeating the request to the client? - ANSWER: Allow the client
time to formulate an answer.
A nurse in an emergency department is admitting a client who reports experiencing a
headache and heart palpitations after having a glass of wine 1 hr ago. The client has
a history of depression and a blood pressure of 210/105 mm Hg and temperature of
39.9 C (103.8 F). Which of the following actions should the nurse take first? -
ANSWER: Determine the client's prescribed medication regimen.- The first action the
nurse should take when using the nursing process is to assess the client. By
determining the client's prescribed medications, the nurse can determine the cause
of the hypertension, such as the client taking an MAOI to treat depression. These
medications can precipitate a hypertensive crisis if consumed with tyramine-
containing foods, including wine.
A charge nurse is preparing an education session for a group of newly licensed
nurses to review client rights under the law. Which of the following statements
, should the nurse make? - ANSWER: "In the event a client threatens harm to others,
medications can be administered without consent."
A nurse is caring for a group of clients. Which of the following findings should the
nurse report? - ANSWER: A client who is taking lamotrigine and has developed a rash
A nurse is providing teaching to a client who is to begin undergoing light therapy at
home. Which of the following information should the nurse include in the teaching? -
ANSWER: Avoid looking directly at the light during treatment.
A nurse is planning discharge for a client who has bipolar disorder and has a
prescription for lithium. Which of the following client statements indicates
understanding of the teaching about the medication? - ANSWER: "I should eat a
regular diet with normal amounts of salt and fluids."- The nurse should identify that
this statement indicates that the client understands the teaching because normal
levels of sodium and fluid need to be maintained to ensure adequate excretion of
lithium. If sodium levels are low, the body compensates by decreasing lithium
excretion, which can lead to toxicity.
A nurse in a community
health center is counseling a family of two parents and two children. Which of the
following statements by a family member indicates manipulative behavior? -
ANSWER: "If you do my homework for me, I won't bother you for the rest of the
day."
A nurse in a mental health clinic is caring for a client who has bipolar disorder and
reports that they stopped taking lithium 2 weeks ago. The nurse should recognize
which of the following as an expected adverse effect that might have caused the
client to stop taking the medication? - ANSWER: Hand tremors
A nurse is caring for a client in a mental health facility. The nurse overhears another
staff member make derogatory comments to the client. Which of the following
actions should the nurse take? - ANSWER: Report the occurrence to the charge
nurse.
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? -
ANSWER: Gather supplies for endotracheal intubation
While observing group therapy, a nurse recognizes that a client is behaving in a way
suggestive of dependent personality disorder. Which of the following behaviors is
consistent with this condition? - ANSWER: The client needs excessive external input
to make everyday decisions.
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent
who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL