1.A client diagnosed with a neurocognitive disorder is disoriented,unsteady and wanders. Which is th

1.A client diagnosed with a neurocognitive disorder is disoriented,unsteady and wanders. Which is the priority nursing concern? The risk of having a disturbed thought process The risk of experiencing a self-care deficit The risk for injury The risk of demonstrating an altered healthcare maintenance 2. A nurse caring for a client with Alzheimer’s diseases who has been hospitalized for treatment of pneumonia. During the night shift, the client is found climbing onto another client bed and frightened. Which of the following actions would be most appropriate of the nurse to make? Assist the client to the correct room Place the client in restrains 3. Which assessing a client, the nurse notes that she is complaining of feeling nauseous and having loos stool, her hands are shaking, and she is talking quickly. Which of the following identify these symptoms can be associated with? Opioid abuse Depression Paranoia Anxiety5. A client bas been prescribed phenelzine for diagnosis of major depressive disorder. The client shows an understanding of the dietary needs by selecting which of the following? A grilled chicken breast with corn on the cob and sweet tea A pepperoni pizza chicken wings and diet soda An avocado salad with aged cheese and a glass of wine A slice of chocolate cake with glass of milk 6. Nurses often work with client who have experienced traumatic experience. Working with these clients can leave the nurse with compassion fatigue. Which of the following would symptoms of compassion fatigue? DepressionInsomniaPessimismJoyfulness Motivation 8. A client diagnosed with obsessive compulsive disorder is ready for discharge. As the nurse reviewing the orders, which of the following would be an expected part of the discharge? An antipsychotic, such as haloperidol with group therapy A benzodiazepine, such as lorazepam with family therapyA mood stabilizer, such as lithium with psychoanalytical therapy A SSRI, such as fluvoxamine with cognitive behavioral therapy 9. A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of locked unit several times. He yells. “I have to leave barber. I see him every Wednesday. Let me out” which of the following would be the most therapeutic response by the nurse? You need to come and take a shower before you can go get your hair cutPlease top banging on the door. Your room is right over there The door is clocked so that you don’t leave and get hurt It’s Monday, and you’re in the hospital. I’m your nurse 10. A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. “I should have died because I am no good to anyone.” Which of the following be the best respond by the nurse? You have a great deal to live for It’s not unusual for depressed people to feel that way Why do you feel you are no good to anyone?You’ve been feeling that your life has no meaning 11. The use of restraint or seclusion is a last resort when other least restrictive measures have failed. What are some reason that would justify the use of restraints or seclusion? (Select all that apply). The client is an immediate threat to themselves or others The client requests seclusion There is a shortage of nurses on the unit The client refuses to participate in group therapy The client has been involuntarily admitted for treatment  12. A nurse is caring for ac client prescribed alprazolam for panic disorder. Which statement by the client shows an understanding of the medication? I’ll need to watch my diet and avoid thin like cheese I won’t be able to have eggs anymoreI have to watch my sodium intake I know not to drink wine or beer 13. While assessing a 78-year-old client diagnosed with dementia, the nurse observes the client has slow responses and difficulty finding the right words. What is the nurse best respond? Suggest words the client may be trying to remember Ask the client, “Are you having problems saying what you mean?”Use silence to allow the client an opportunity to compose responses Discontinue the assessment to prevent further frustration to the client 14. When assessing a client for suicide, which aspect has the highest priority? The client’s financial and educational status The availability of means and lethality of the selected method The client’s night into suicidal motivations The quality and availability of the client’s social supports15. A client recently diagnosed with acute stress disorder (ASD) asks the nurse how this diagnosis is different from post-traumatic stress disorder (PTSD). Which of the following is it? Whereas PTSD is caused by a traumatic event; acute stress disorder is not The major difference between the disorders is the timeframe from which the traumatic event occurred Only a diagnosis of PTSD will experience nightmares Only a diagnosis oof acute stress disorder will experience flashbacks 16. 1 ounce=_____mL20153930 17. A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication? Lab work is only needed at the start of taking the medications Once I feel better, I will not need to take this medication anymore There is a chance I may become addicted to this medicationI need to be aware of situations that may cause dehydration 18. A family member of a client recently diagnosed with obsessive-compulsive disorder (OCD) asked the nurse to explain the difference between an obsession and a compulsion. It would be which of the following? Compulsions and obsessions include an action and thought, but they are motivated by different desires We are still learning to understand how the brain processes obsessions and compulsions Obsessions are repetitive thought uncontrolled by the client, and compulsions are the behaviors done that are typically associated with obsessive thought Obsessions and compulsions are really same things, both of which the client have no control over 19. A client asking about stress reduction techniques which they could use daily. Which response by the nurse would best represent a technique the client could use?It will be important to have your doctor write a prescription for assistanceYou can find multiple guided deep breathing exercises on the internet If it were me, I would try all of them before making a choiceOnly physical activity on a daily basis has shown to decrease a person’s stress20. A nurse working on an in-patient psychiatric unit observes a client diagnosed with obsessive-compulsive disorder (OCD) rearranging the magazines in the dayroom. The nurse understands primarily meant to do which of the following? Ensue a structured and orderly environmentShow the other clients how to stay organizedTemporarily reduce he anxiety the client is feeling Show the nursing staff they can handle emotions 21. A nurse is assigned to a client diagnosed with obsessive-compulsive disorder (OCD). Which of the following nursing actions should be incorporated into the client’s care? Encourage the client to avoid situations that increase anxiety Prevent the client from performing compulsive behavior Explain to the client how the compulsive behavior is excessive Allow time for the client to complete compulsive behaviors 22. 1 Tablespoon-_____mL?15258010023. A client has been prescribed buspirone for a new diagnosis of generalized anxiety disorder (GAD). Which statement by the client indicates an understanding of medication? I will only need to take this when I feel anxious I should begin to feel better in a few days I will let my physician know if I become addicted I will need to take this medication for a while before I see how well it works for me24. The daughter of a client with dementia has been her primary caregiver. The daughter expresses to the nurse. “At times, it is so overwhelming I feel I do not have a life an more” what is the nurse most appropriate response? Are you saying you don’t want to care for your mother anymore?I know it is really hard. It takes a lot of work, and you are doing such a good job.Your mother really appreciates what you do for her. You are the best one to care for her There is a local caregiver support group. How do you think you would feel talking with others in the same situation?  25. A nurse is caring for a client who has dementia. When performing a Mini-Mental Status Examination (MMSE), the nurse should include which of the following data? (Select all that apply). The ability to show attention Current cropping skills Immediate recall ability Level of orientation Nutritional status 26. A nurse is caring for a client with post-traumatic stress disorder (PTSD). Which statement from the client indicates the client is experiencing hypervigilance? I’m having trouble sleeping at night I haven’t been able to feel emotions lately I always have to be aware of my surroundings Certain noises scare me 27. A client is scheduled for series of diagnostic tests due to reported history of smoking, recent weight loss, constant cough, and reports of becoming easily fatigued. The client stats absolutely nothing wrong with me; I just have a stubborn chest cold. What of the following defense mechanisms does the nurse recognize the client may be using? Displacement Denial Humor Projection28. A nurse is admitting a client experiencing chronic stress. Which of the following findings should the nurse expect? The client is experiencing low blood pressureThe client has been getting sick frequently The client states they have large amounts of energy The client experiencing a greater awareness of their situation  29. While caring for a client admitted with depression, the client states, “Everything is going to be just fine now” Which of the following would e the most appropriate nursing response? I’m glad you have a positive outlook on life You’re right. The medication are starting to work When you say, “everything is going to be fine”. Can you tell me what that means?You seem to be feel better 30. While discussing with a client newly diagnosed with obsessive-compulsive disorder (OCD), the client asks, “What are considered to be common compulsions? Which of the following best response by the nurse? Often the compulsions are centered around the illness and death We really haven’t seen any compulsions to be common Common compulsions can include hand-washing and checking door multiple times to make sure it’s clocked Each person will have their own unique compulsion 31. A nurse caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client dose which of the following? Displays repetitive behaviors Reminisces about the past Makes up stories when he is unable to remember events Refuses to leave homes to see a provider 32. A client diagnosed with obsessive-compulsive disorder (OCD) has been prescribed fluvoxamine. Which statement by the client shows an understanding of this medication? I will need to avoid cheese and aged meats I may experience dry mouth I will need to monitor my sodium intake I will need to tell my doctor if I have any suicidal thoughts  33. While learning about depressive disorder, a client understands the difference between major depression disorder and persistent depressive disorder when they can stat which? Major depression is more serious than persistent depressive disorder Persistent depressive disorder is a chronic form of depression lasting more than two yearsPersistent depressive disorder is more common than major depression Major depression impairs a person’s ability to function, but persistent depressive disorder does not 34. A client with major depressive disorder has been admitted to the in-patient psychiatric unit. Which displayed behavior would indicate the need for a follow-up of a suicide assessment? The client’s family members canceled their schedule visit The client has chosen not to attend group therapy The client appears to be happy and peaceful, which is a change from previous days The client has eaten less than 50% of their meals 35. A client in a manic phase has not been eating during mealtime because they have been unable to sit still for the designated time period as they are constantly pacing around, what would be a possible meal option for the client to help ensure they are meeting their dietary needs?The client needs to learn to manage their excessive energy and eat with the rest of the clients Offer the client a high-calorie protein drink instead of a sit-down meal Have the client sit separately in their room with minimal distractions Request a doctor’s order for a nasogastric tube placement for feeding 36. A nurse working on acute menial health unit is caring for a client diagnosed with major depressive disorder. Which of the following is the heights priority or the nurse? Ensuring the client attends group therapy as scheduled Ensuring the client’s safety, including close monitoring Reviewing the client’s ability to complete their-self-care needs Informing the client of the medications they have been prescribed 38. A nurse is caring for a client experiencing panic level anxiety. The nurse understands which of he following actions should be considered a priority?Guide the client through relaxation techniques Stay with the client and reduce the stimuli in the room Ask the family member what the trigger for the anxiety wasAllow the client to remain alone to recollect themselves 39. A client with depression is taking tricyclic antidepressants. He states, “I don’t want to keep taking these pills. Now I get dizzy when I stand up. “Which would be the most appropriate response by the nurse? Orthostatic hypertension is a side effect of the medication. Before standing, rise slowly from a laying to sitting position firstDizziness is a concerning side effect. I will inform the physician of your decision I will take your blood pressure and make sure there is nothing else going on I would think feeling dizzy is better than feeling depressed40.  The client, a veteran of the war in Iraq, is diagnosed with post-traumatic stress disorder (PTSD). His psychiatrist has recently recommended the begin eye movement dissertation (EMDR) therapy. Which statements by the client shows an understanding of the therapy? I will be able to share my experience with others who have same disorder I will use skills such as mindfulness to evaluate emotional situations 41. During an admission a veteran diagnosed with post-traumatic stress disorder (PTSD) states, “Sometimes I just drink until I can’t feel anything anymore.” What should be considered?The client needs to go through detoxification before treatment The client needs to be educated about the negative impacts of excessive alcohol use The client needs to be further evaluated for possible substance abuse disorderThe client is coping in a positive manner 42.A client with major depressive disorder has been admitted to the patient psychiatric unit. Which displayed behavior would indicate the need for a follow-up of a suicide assessment? The client’s family members canceled their scheduled visits The client has chosen not attend group therapy The client appears to be happy and peaceful which is change from previous days 43. A client with vascular dementia is experiencing agnosia. She sits her dining table looking at her food but does not pick up a utensil and try to eat. What intervention is most appropriate nurse to try first? Send the food back to the kitchen and try something else Help the client by feeding her Hand the fork to the client and say, “Use this fork to eat your meatloaf” Tell the client, “It’s time to start eat. Those potatoes look good” 44. A 36-year-old teacher with a history of anxiety is admitted to the emergency room. The nurse understands common symptoms of panic level anxiety will include which of the following?Feeling pain, hunger, and confusion Feeling sad tired, and expressions of minimal emotion Feeling impending doom, chest tightness, and hypertension Feeling overwhelmed and “butterflies” in stomach 45. While being treated for a deliberate overdose attempt, the client says to the nurse, “My boyfriend broke up with me. We have been together forever. I just love him so much. I don’t supposed to live without him.” Which is the best response by the nurse? It seems as thou you are very sad about your lossDon’t worry, there are other fish in the sea Why do you think he broke up with you? In time, you will be able to move past this pain 46. 0.75 g =__________mg?75050020030047. A nurse receives a laboratory result of a lithium level of 1.8 mEq/L. How would the nurse interpret this lab value? It is within therapeutic limits It is below therapeutic limits It is above therapeutic limits A redraw will need to be completed as this an error  48. A veteran of the Iraq War describes that he is having intrusive thoughts including hearing missiles, screaming, explosions, and feeling the same feelings of tremor first experienced nurse would recognize these symptoms are most likely associated with which diagnosis? Obsessive-compulsive disorder Generalized anxiety disorder Panic disorder with agoraphobia Post-traumatic stress disorder 49. A client is secluded after striking a staff member. While speaking with the nurse, the client states, “They shouldn’t have provoked me. “Which of the following defense mechanisms identify the comment as reflecting? Denial RationalizationHumor Sublimation 50. A client diagnosed with major depressive disorder is telling the nurse. “My life doesn’t have any happens in it anymore, I used to care about going out with friends, and now I don’t invite me.” The nurse recognizes this as an example of which symptom? Anergia AnhedoniaEuphoria Affect flattening 51. The nurse practitioner orders gentamycin 55 mg IM every 8 hours. On hands is gentamycin 80 mg/ 2mL. How many mL will the nurse administer each dose? (Round answer to the nearest decimal place. Use a leading zero if applies. Do not use a trailing zero.)1.41.804.90333 52. A client diagnosed with bipolar disorder has recently been started on lamotrigine as part of their medication regimen. Which of the following would be an essential teaching point about the medication? You will need to monitor your sodium intake closely while on this medication If you experience a rash, you should notify your physicianYou will need to monitor your weight while taking this medication It is important for you not to become pregnant while taking this medication 53. Goals and desired outcomes for an older adult client experiencing delirium caused by fever and dehydration will focus on which of the following? The client will return to premorbid level of function The nurse will identify stressors negatively affecting the client The client will demonstrate limited motor responses to the external stimuli The client will be able to exert control over responses to perceptual distortions 54. A nurse caring for a 55-year-old male client newly diagnosed with post-traumatic stress disorder (PTSD). The nurse knows as part of the disorder to anticipate which of the following symptoms? Pain without a medical cause Counting and re-checking of objects Nightmares and hallucinations Trouble maintaining boundaries 55. A nursing student is learning about the difference between bipolar disorder. When asked to the explain the main difference between bipolar I and bipolar II, the student shows, explaining which of the following?There are different medications used to treat the disorders Each disorder has a different duration and type of mania Bipolar II has anxiety symptoms that must be displayed Bipolar I dose not experience mood swings, just mania  56. A client experiencing acute mina approaches the nurse, waving a newspaper saying, “I must make a phone call right this second I need to call a store while their sale is going on I need and four pairs of shoes” Which of the following would be the most appropriate intervention for the nurse to implanted? Explain the phone is available during certain hours, and the client must wait Suggest to the client a family member can do the shopping for them Allow the client to use the phone to make the purchaseRedirect the client energy by inviting them to sit and look through a magazine with the nurse57. A nurse is caring for an elderly client. Which of the following would be a sign of change in mentation and possible delirium from a urinary tract infection? The client is climbing out of bed repeatedly and stating she must get to the bank The client is refusing to bathe The client refuse to get out of bed and wants to sleep all-day The client has an elevated body temperature58. Which statement by a client experiencing sever anxiety may indicate the possibility of obsessive-compulsive disorder (OCD)? I have keep checking to see where my keys are I’m afraid to go out alone in public I keep seeing the accident over and over My arms feel weak 59. A provider orders ondansetron 8 mg by mouth (PO) to be given three times a day. On hand is ondansetron elixir 4 mg /5 mL. How many mL will the nurse administer each dose? (Round nearest whole number. Do not use a trailing zero) 105120 60. A nurse is preparing to administer phenytoin oral suspension 300 mg PO. Available is phenytoin oral 125 mg/5mL. How many ml should the nurse administer? (Round nearest whole number. Do not use a trailing zero.)12109661. A client recently diagnosed with post-traumatic stress disorder (PTSD), describes moments where he feels as though he is completely reliving the experience, even smelling a gun, which statement by the nurse shows an understanding of the symptoms the client is experiencing?Hypervigilance can occur, where your sense are heightened, and you are more situationally aware with PTSD It uncommon to have these experiences we should let the doctor know It wounds as though you experienced an intense nightmare regarding the memories A flashback is when you relieve the experience and include all the sense, as it sounds you experienced 62. Following a failed suicide attempt, the client tells the nurse, “I’m going to try this again, and nest time I’ll choose a no-fail method” which is the best appropriate response by the nurse? You are safe here, and we will keep you here to make sure nothing happens to you It’s luck your roommate found you when she did I don’t understand, you have so much to live for What are planning to do?63. A nurse is caring for a client who is given a prescription for lorazepam. While reviewing the client’s medical record, which part of the history would raise concern for this patient? A history of a control seizure disorder A history of post-traumatic stress disorder A history of alcohol abuse A history of auditory hallucinations  64. A client is admitted to the hospital for abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure. Upon review, the client has been taking sertraline, but recently were switched from another medication, phenelzine. Which of the following does the nurse recognize is most like experiencing? Neuroleptic malignant syndrome Withdrawal from phenelzine Serotonin syndrome Overdose of sertraline 65. During the initial interview with a client being admitted with history of depression and current suicidal ideation, the nurse asks if anything is happening in life responds, “There’s nothing wrong. My life is perfect.” Which of the following defense mechanisms does the nurse recognize this as an example of? Sublimation Displacement Projection Denial66. A client with bipolar disorder has just been started on Valproic acid. As part of the client’s monitoring, the nurse is aware of which of the following? Baseline blood glucose testing will be required The client will need to report any seizure activity Potassium intake will need to be carefully monitored baseline laboratory work for liver function test will be needed 67. A client with history of post-traumatic stress disorder (PTSD) is pacing and yelling at the staff in their room. As the nurse is approaching to communicate with the client, which of the following is the best approach? Remain calm, use a neutral tone when speaking, and maintain a safe distance Use an authoritative approach with a stern voice for providing directions Allow the client to continue to express themselves without interfering Remain calm, using a gentle voice and therapeutic touch to guide the client 68. A client weighs 125 lb. What is the client’s weight in kg? (Record answer to the nearest tenth, one decimal place. Do not use a trailing zero,) 56.85.866.920.169. Which statement by the client would warrant further investigation regarding the risk for suicide? I’m glad these medications have improved Everything is going be okay now My family has been a major support I reviewed my living will this year 70. A nurse is admitting an older client who has suspect cognitive disorder. Which of the following tools should be included as part of admission assessment? Brief patient Health Questionnaire (Brief PHQ) Mental Status Examination (MSE) Abnormal Involuntary Movement Scale (AIMS) Scale for Assessment of Negative Symptoms (SANS) 71. An older adult client with Alzheimer’s disease lives with family and goes to daycare on weekdays. The nurse at the center observed poor hygiene and discussed this observation with the adult child. The caregiver became defensive and said, “I’ll take all my time and energy to care for my other. She is awake all night. Last night she fell down the stairs.” Which nursing intervention highest priority in this case? Inform the caregiver more about the effects of Alzheimer’s disease Secure additional safety measures for the mother’s evening and night care Support the caregiver to grieve the loss of the mother’s ability to function Demonstrate to the family how to give physical care more effectively and efficiently  72. A 29-year-old female client has recently been diagnosed with bipolar disorder and has been prescribed Valproic acid. What teaching must be provided to the client regarding the medication? Every month, you will need to be weighted You will need to monitor your sodium in while on the medicationThere is a chance of developing dependency on the medicationYou will need to ensure you are using preventive measures when sexually active73. A nurse working in an outpatient client has been completing the initial intake interview. Which of the following clients has an increased risk of suicide? (Select all that apply)A client who has been selected for a promotion A client with a family history of suicide A client diagnosed with cancer who is in remission A client who was abused as a child A client who is having legal problems 74. A client with suicidal impulses has been admitted to the in-patient psychiatric unit with suicide precautions ordered. Which measures should be incorporated into the plan of care? Ensure there is no metal or glass on meal trays Assign the client a private room with door closed Remove all potentially harmful objects from the client’s possession Monitor the client only when they are awake or engaged in activities Encourage client to speak to nurse if increased suicidal thoughts occurs 75. On discharge a client is receiving a new prescription for donepezil. Which statement by the family would show an understanding of the medication? Donepezil is a sedative used for short-term treatment of insomnia Donepezil is a treatment used in all stages of Alzheimer’s disease. Donepezil is an antipsychotic used to treat neurocognitive disorders Donepezil s an anti-anxiety medication used to treat dementia75. Two days ago, a client was admitted to the in-patient psychiatric unit with a diagnosis of post-traumatic stress disorder (PTSD). He continues to have sleep problems and trouble with expressed increasing anger toward another client who reminds him of a former employer. Which of the following would nurse recognize as the highest priority nursing concerns is? Experiencing nightmare Having self-care deficit The risk for violence Demonstrating ineffective coping 76. A nurse is caring for a client admitted with a diagnosis of bipolar I disorder and currently in a manic state. Which of following symptoms would the nurse expect to observe? (Select all that apply). Inflated self-esteem An increased need for sleep Increase in risky behavior Flight of ideas Limited verbal communication 77. The nurse is preparing to discharge an 86-year-old client diagnosed with Alzheimer’s disease. The nurse is reinforcing discharge education with the client’s family, who will be caring intervention would be beneficial for this client’s family? Discourage wandering by installing complex locks or locks placed at the tops of doors where the client cannot readily reach themFor situations in which the client becomes upset, instruct her family to seclude her in her room for an hour, being sure to turn off the television or other simulating Recognize that the client can no longer successfully interact with others; provide a darkened quiet room for her spend her time Hire an off-duty police officer to watch the home in case she tries to wander away     Health ScienceScienceNursing MENTAL HEALTH PRN1562 Share QuestionEmailCopy linkComments (0)

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