Client is shouting in a terrified voice about bugs on him which are not there. What is a therapeutic response?

You seem frightened, but I do not see any bugs

A client tells you they feel suicidal. What is your best response?

"I will be sharing this information with the team to keep you safe"

What are hallmark symptoms of ADHD?

Inattention, hyperactivity, and impulsivity

Which of the following is an intervention to be used with a client who has dementia?

Limit the client's choices for daily activities

A client has anxiety. Which response should the nurse make?

"Tell me what has been happening lately"

Client has hallucinations. What action should the nurse take?

Ask the client direct questions about the hallucination

What nursing intervention should the nurse implement to someone who is uncomfortable with touch?

The nurse should avoid touching during interactions if possible

A client is in seclusion. What is the priority intervention?

Maintain contact with the client and assure client's safety

You notice a client having a severe reaction to medication. What is your best response?

Assess patient, hold medication, contact provider

Client has generalized anxiety disorder. What intervention would promote relaxation?

Assist the client to practice meditation

Nurse is providing care for a client who has anorexia. What is the frist action the nurse should take?

Ask the client to talk to the nurse whenever she feels the urge to exercise

Which meal would the nurse approve for a client on an MAOI?

Ground beef patty and mashed potatoes

A nurse is caring for a client who has Alzheimer's. Which of the following should be included in the plan of care?

Provide a consistent daily routine

Nurse is planning discharge of client with anxiety. Which of the following should be in the discharge instructions?

Identity anxiety-producing situations

Regarding documentation in client record

Court considers not documented as not done

Which of the following behaviors would imply a teenager still has suicidal intent?

Planning to give away his most prized possessions to his partner

What is the appropriate action when a client threatens harm to another individual?

I need to make sure the potential victim is warned

When can the nurse break patient confidentiality?

Providers are required to warn individuals if the client threatens them

What is an adverse effect of carbamazepine? Must know ALL major adverse effects of medicine for final

Blood dyscrasias such as leukopenia, anemia, and thrombocytopenia

A nurse is teaching about restraints. What would be an indication to put restraints on client?

Self-destructive behavior despite alternative interventions

What should the nurse do to establish a therapeutic relationship?

Demonstrate genuineness and authenticity when communicating

A nurse is teaching about methyphenidate. What should be included in the teaching?

"Restict your child's intake of caffeine while taking the medicine."

What is the priority intervention for a client that has attempted to die by suicide?

place client on 1 to 1 observation

What should you teach a client about disulfiram?

Taking this medication with alcohol is dangerous

What is the priority intervention for a client with anorexia nervosa?

Assessment of VS and anticipate medical concerns

What is an appropriate instruction for a client on lithium?

Maintain normal salt and fluids in the diet

A nurse is caring for a client whose partner died five years ago. What indicates maladaptive grief?

The client has kept his partner's closet untouched since her death

Client says, "I see headless people walking down the hall at night." What should nurse say?

It must be frightening to see a headless person, but I do not see anybody"

Nurse is caring for older adults?Which of the following manifestions would indicate the client is experiencing delirium?

A client attempts to climb out of bed and states she has a baby at home

When planning care for a client with dependent personality disorder, what intervention is priority?

Give positive feedback when assertive with staff or clients

What is the priority nursing diagnosis for a client with anorexia nervosa?

Imbalanced nutrition less than body requirements related to starvation

A nurse is planning care for a client with OCD. Which of the following actions should the nurse take?

Investigate what situations precipitate anxiety

Family member says, "I wish I could stay, but I need to get home to my children." What should nurse say?

"You are feeling drawn in two separate directions."

What is an important teaching point about sertaline?

This medication may cause an inability to orgasm

What question should you prioritize in an effort to determine the client's risk for suicide?

Do you ever feel like your situation is hopeless?

studbud

Final Exam Review Fall 2023

99 termsStudBud Administration90 plays

Review for Final Exam. The content is what should be focused on for the final

Flashcards99 cardsFPractice quizPHost liveL

Questions 99

Answers

1
Client is shouting in a terrified voice about bugs on him which are not there. What is a therapeutic response?
I do not see anything.
You seem frightened, but I do not see any bugs
You have lice!
Those bugs will not hurt you
2
A client tells you they feel suicidal. What is your best response?
"It would be a HIPPA violation for me to tell anyone"
"Please think about sharing this with the nurse practitioner"
"I will be sharing this information with the team to keep you safe"
"You will feel better in the morning. We will talk then."
3
What are hallmark symptoms of ADHD?
Hypersomnelence, hyperactivity, and hyperagitation
Hyperactivity, anger, and inattention
Inattention, hyperactivity, and impulsivity
Impulsiveness, conduct, and aggressiveness
4
Which of the following is an intervention to be used with a client who has dementia?
Rotate staff
Limit the client's choices for daily activities
Provide a cognitively stimulating environment
Use confrontation to manage negative behavior
5
A client has anxiety. Which response should the nurse make?
"Tell me what has been happening lately"
"It doesn't appear as though uou are feeling anxious"
"Do you think your anxiety is worse than everyone elses?"
"I think you should see a therapist"
6
Client has hallucinations. What action should the nurse take?
Instruct the client to argue with the voices
Ask the client direct questions about the hallucination
Tell the client the hallucinations are not a part of reality
Act to the client as if the hallucination is real
7
What is a sign or symptom of serotonin syndrome? Know the s/s of serotonin syndrome
Still body
Fever
Hyporeflexia
Client is thinking clearly
8
What nursing intervention should the nurse implement to someone who is uncomfortable with touch?
The nurse should avoid touching during interactions if possible
The nurse should touch the client to practice systematic desensitization
The nurse should teach the client to incorporate touch in communication
The nurse should wear gloves during client interaction
9
A client is in seclusion. What is the priority intervention?
Have little contact with the client to decrease stimulation
Maintain contact with the client and assure client's safety
Teach client relaxation techniques
Provide the client with privacy
10
You notice a client having a severe reaction to medication. What is your best response?
Hold medicine, order labs
Contact family for history, send text to provider
Check lab values, discontinue medicine
Assess patient, hold medication, contact provider
11
Client has generalized anxiety disorder. What intervention would promote relaxation?
Assist the client to practice meditation
Recognize the client's spiritual preferences
Help the client identify his previous accomplishments
Encourage the client to identify his positive qualities
12
What is an intervention for mania? Know different types of interventions
Discourage client from napping
Offer finger foods
Weigh client every 3-4 days
Encourage client to attend group
13
Nurse is reviewing labs for a client on clozapine. Which lab indicates clozapine should be stopped?
A client with has a serum potassium of 3.3
A client with a BUN of 22 mg/dl
A client with a hematocrit of 55%
a WBC count of 2,900 cells/mm3
14
Nurse is providing care for a client who has anorexia. What is the frist action the nurse should take?
Restrict the client from being weighed
Praise the client for looking at herself in mirror
Reprimand the client about the potential damage that has occurred
Ask the client to talk to the nurse whenever she feels the urge to exercise
15
What nutrient is lacking in wernicke/korsakoff syndrome?
Vitamin C
Thiamine
Vitamin E
Folate
16
Which meal would the nurse approve for a client on an MAOI?
Macaroni and cheese
Pepperoni pizza
Noodles with chedder cheese
Ground beef patty and mashed potatoes
17
What would be considered manic behavior? May be more types on the exam
Rapid, continuous speech
Sitting down for a meal
Sleeping long periods of the day
Dressing in all black
18
You notice a client with schizophrenia has restlessness and an inability to sit still. What medicine do you anticipate?
Benztropine
Clonidine
Haloperidol
Lithium
19
Client is in restraints. When can the nurse release the client?
The client requests to use the bathroom
The client eats all of the food provided
The client's vital signs are stable
The client follows directions
20
A nurse is caring for a client who has Alzheimer's. Which of the following should be included in the plan of care?
Provide a consistent daily routine
Allow the client to choose free-time activities
Post a written schedule of daily activities
Use an overhead loud speaker to announce events
21
Nurse is planning discharge of client with anxiety. Which of the following should be in the discharge instructions?
Contact crisis counselour once a week
Try to repress feelings of anxiety
Identity anxiety-producing situations
Eliminate stres and anxiety from daily life
22
Regarding documentation in client record
Stereotypes are useful and beneficial
It is okay to change someone else's documentation
Opinions are important
Court considers not documented as not done
23
Which of the following behaviors would imply a teenager still has suicidal intent?
Stating that he wants to be with his peers more than his parents
Telling his parents that he doesnt want to talk about his previous attempt
Planning to give away his most prized possessions to his partner
Preferring to eat his meals while watching t.v.
24
What is the appropriate action when a client threatens harm to another individual?
I need to keep this information confidential
I should report this to the psychiatrist
I need to make sure the potential victim is warned
I can only discuss the client's threat with a court order
25
When can the nurse break patient confidentiality?
When the client dies, confidentiality may be broken
Staff has to tell information to attorneys
Nurse's can never break confidentiality
Providers are required to warn individuals if the client threatens them
26
What is an adverse effect of carbamazepine? Must know ALL major adverse effects of medicine for final
Hand tremors
Serotonin Syndrome
Blood dyscrasias such as leukopenia, anemia, and thrombocytopenia
Tardive dyskinesia
27
Which of the following would you expect in a newly admitted client with anorexia nervosa? Know s/s of anorexia
Normal menstrual cycle
Verbalized desire to gain weight
Desire to exercise
Tachycardia
28
What is clonidine used for? Know purpose of naltrexone, lorazepam, and disulfiram related to substance use also
Alcohol withdrawal
Alcohol cravings reduction
Opioid withdrawal
Alcohol deterent
29
A nurse is teaching about restraints. What would be an indication to put restraints on client?
Punishment for verbally abusing other clients
Discipline for yelling at staff
Self-destructive behavior despite alternative interventions
Coercion to take medicine
30
What should the nurse do to establish a therapeutic relationship?
Control the pact of establising the nurse-client relationships
Demonstrate genuineness and authenticity when communicating
Provide sympathy during interactions
Focus on the words of the clients
31
A nurse is teaching about methyphenidate. What should be included in the teaching?
"Your child might gain weight while taking this medicine."
"This medication might increase the amount of saliva."
"Administer the medicine at bedtime."
"Restict your child's intake of caffeine while taking the medicine."
32
What is the priority intervention for a client that has attempted to die by suicide?
Teach coping skills
Assess the specific motivations
Help manage anxiety
place client on 1 to 1 observation
33
Client is on lamotrigine. What severe adverse effect is associated with this drug?
Neuroleptic Malignant Syndrome
Metabolic Syndrome
Agranulocytosis
Steven-Johnson Syndrome
34
What should you teach a client about disulfiram?
Taking this medication with alcohol is dangerous
Take the medicine after drinking alcohol
Do not take tyramine-containing foods
This medicine cures alcoholism
35
Client is withdrawing from opioids. What medication should the nurse anticipate administering?
Risperidone
Lithium Carbonate
Disulfiram
Methadone
36
What is the priority intervention for a client with anorexia nervosa?
Assess family issues
Assess mother-infant interactions
Assess client's knowledge of SSRI's
Assessment of VS and anticipate medical concerns
37
The nurse does not harm the client . This is an example of what ethical prinicple? For exam, must know all 4 principles
Veracity
Autonomy
Nonmaleficence
Beneficence
38
What is an appropriate instruction for a client on lithium?
Maintain normal salt and fluids in the diet
Drink twice the amount of water
Double the lithium dose if diarhea or vomitting occur
Avoid eating aged cheese and processed meats
39
A nurse is caring for a client whose partner died five years ago. What indicates maladaptive grief?
The client has kept his partner's closet untouched since her death
The client joined a bowling league 2 months ago
The client exercises at a local health facility 3 days a week
The client meets his daughter for dinner every week
40
Client says, "I see headless people walking down the hall at night." What should nurse say?
"Now lets talk about that. A headless person would not be able to do that."
It must be frightening to see a headless person, but I do not see anybody"
"Why do you think a headless person would be alive?"
"It is Halloween today."
41
Nurse is caring for older adults?Which of the following manifestions would indicate the client is experiencing delirium?
A client attempts to climb out of bed and states she has a baby at home
A client request extra blankets when the thermostat says it is 78 degrees
A client refuses to get out of bed
A client wants to know the current time while there is a clock on the wall
42
A nurse notices a client with OCD engaged in repetitive cleaning. Why is the client doing this behavior?
Manipulate others
Decreases anxiety
Decrease the time available for interacting with people
Prevent aggressiveness and impulsive behaviors
43
When planning care for a client with dependent personality disorder, what intervention is priority?
Monitor the client for self-harm
Set limits to prevent exploitation
Give positive feedback when assertive with staff or clients
Discourage flamboyant or seductive behaviors
44
What is the priority nursing diagnosis for a client with anorexia nervosa?
Ineffective coping related to lack of conflict resolution skills
Imbalanced nutrition less than body requirements related to starvation
Disturbed body image related to weight loss
Anxiety related to fear of weight gain
45
A nurse is planning care for a client with OCD. Which of the following actions should the nurse take?
Teach the client that compulsive behavior is excesive
Investigate what situations precipitate anxiety
Prevent the client from performing compulsive behavior
Encourage avoidance of situations that increase anxiety
46
What would indicate a client with anorexia should be admitted to hospital? Know other criteria
Heart rate of 38 BPM
Stable weight
Weight gain
Client making appropriate food choices
47
What electolyte is monitored during refeeding syndrome?
Magnesium
Phosphate
Calcium
Sodium
48
Family member says, "I wish I could stay, but I need to get home to my children." What should nurse say?
"Don't worry. We'll take good care of your parent."
"There's nothing you can do. You should go home."
"You are feeling drawn in two separate directions."
"Perhaps you could call your children."
49
What is an important teaching point about sertaline?
A fever is an expected adverse effect of this medicine
This medication may cause an inability to orgasm
You will notice improvement in 2-3 days
Sertraline can cause temporary muscle rigidity
50
Client is experiencing acute alcohol withdrawal. What drug does the nurse anticipate administering?
Diazepam
Clonidine
Naltrexone
Disulfiram
51
What question should you prioritize in an effort to determine the client's risk for suicide?
Is your antidepressant helping you?
How is your relationship with your parents?
Do you ever feel like your situation is hopeless?
How is your relationship with your spouse?
52
Which of the following demonstrates autonomy
Making sure the client understands expectations
Encouraging client feedback about satisfaction with the facility
Explaining the rules and policies regarding unacceptable behavior
Supporting the client wishes to refuse prescribed medication
53
What is a sign of cocaine toxicity?
Hypothermia
Tremors
Respiratory depression
Hypotension
54
Spouse who visited client states, "I am worried about my husband." What should nurse say?
"Your husband is making really good progress. Don't worry."
"DId your husband say something that upset you?"
"Crying helps us all let things go and we all feel better."
"Tell me what is concerning you."
55
Client has end-stage liver cancer. Which of the following responses indicates client is in denial?
"The doctors says I only have a few months to live, but I know he is wrong.
"The doctor has been good to me. It is my time to go."
"Even though I am not hurting now, I do not feel like getting out of bed."
"Doctor, I will give you all my money if you cure me."
56
Which of the following clients may develop EPS from medication therapy?
An adult client who has type 2 diabetes and is taking insulin
A older adults with pancreatitis taking enzymes
A client with schizophrenia and is taking antipsychotics
A client in the 3rd trimester of pregnancy on supplements
57
What is true regarding reporting child abuse?
If suspicion of abuse if present, reporting is mandatory
If you do not want to defame someone, you do not need to report
Evidence must exist prior to reporting
If the abuser says they will stop, no need to report
58
Which of the following puts a client at risk for lithium toxicity?
The client drinks 2 liters of water a day
The client eats food high in tyramine
The client eats 2 to 3 grams of sodium daily
The client runs 4 miles outdoors every afternoon without replensihing fluid
59
A client says drinking is not a problem. What defense mechanism is being used?
Dissociation
Denial
Devaluation
Displacement
60
Client with anxiety is pacing up and down halls. What should nurse do?
Walk with client at a gradually slower pace
Instruct the client to sit down and stop pacing
Have a staff member escort client to room
Allow the client to pace alone until tired
61
Client is taking risperidone. How does the nurse assess for EPS symptoms?
The body attitude test
AIMS
Hamilton Depression Scale
The recovery attitude and treatment evaluator
62
A nurse is teaching about ECT. What of the following should be included?
ECT is effective in the treatment of addictions
Temporary memory loss is the most common adverse effect
Medications are given to prevent seizure activity during ECT
The most common side effect is permanent brain damage
63
What should you teach about sertraline? Know major teaching points of SSRIs
The effects are felt in 1-2 weeks
There are no sexual side effects
Discuss need to take medication even when symptoms improve
There is no consequence to stopping the medication abruptly
64
Which would be the priority for a client with severe neurocognitive disorder like Alzheimer's
Support
Cognitive Intervention
Safety
Education
65
Client has a prescription for valproate. What lab needs to be monitored?
Liver functions such as AST/ALT
Sodium levels
WBC and granulocyte
Kidney function tests such a BUN/Creatinine
66
After transfer to hospital, client does not remember being in a car accident. What defense mechanism is being used?
Sublimation
Repression
Suppression
Projection
67
What would be considered a sign of tranference?
Client believes he has super powers
Nurse sees the client similarly to his own mother
Client blames his mom for failed marriage
Client sees the nurse similarly to his own mother
68
Client says, "I can't sleep. I stay up." Nurse says, "You have difficulty sleeping." What technique is being used?
Restating
Giving information
Offering advice
Offering general leads
69
What is a symptom of alcohol withdrawal? Know all symptoms of withdrawal
Visual hallucinations
Severe hypotension
Gooseflesh skin
Bradycardia
70
Client say, "I am tired of feeling this way. Nothing ever goes right." What is most appropriate nursing response?
"Are you sure nothing EVER goes right?"
Don't cry. Look at the positive of life."
"You are feeling sad right now and it is a hard time."
"Hang in there. The meds will start helping soon."
71
Nursing care for a a client with dementia includes all the following EXCEPT
Break instructions and activities into short timeframes
Change caregivers daily
Provide memory aids such as photos of loved ones
Assure environmental safety such as remove rugs
72
Client with schizophrenia is medicated with haloperidol. What should the nurse look out for?
Pancreatitis
Cardiac Dysrhythmias
Cataracts
Bleeding
73
Client says, "No one cares. Life is not worth living." What shouls nurse say?
"Of course people care. Your family comes to visit every day."
"I care about you and I am concerned that you feel so sad."
"Tell me who you think doesn't care."
"Why do you feel that way?"
74
A nurse is assessing a client who has PTSD following a sexual assault. What is an expected finding?
Increasing feelings of anger
Sleeping 12 hours a day
Increasing sense of attachment to others
Constant need to talk about event
75
Voluntary clients may refuse medications as long as they are not a threat to themselves or others
False
True
76
How long until SSRIs are effective to treat depression?
2-3 Months
4-6 Weeks
1-2 Weeks
2 Days
77
Client has panic level anxiety and is shown to his room. What should nurse do next?
Suggest that the client rest in bed
Have the client join a therapy group
Remain with the client for a while
Medicate client with a sedative
78
Client says, "I am thinking about ending it all." What should nurse respond?
"Why would you want to do something like that?"
"Your attitude will hamper your recovery."
"Wasn't your wife here during visiting hours?"
"You must be feeling sad right now."
79
What is the priority intervention for a client with histrionic personality disorder?
Promote appropriate behavior during therapy sessions
Demonstrate assertive behavior
Encourage client input in the treatment plan
Communicate using concrete language
80
A client is on methylphenidate. Which information should the nurse provide?
An adverse effect is decreased ability to learn
Admintster medication before the child has breakfast
Administer medication at bedtime
Double the dose if one is missed
81
What would be the most therapeutic statement to client responding to auditory hallucinations?
How did you sleep last night?
Are you hearing something?
Would you like a snack?
Its a beutiful day today.
82
A nurse is assessing a client with anorexia. What should the nurse expect?
Hypertension
Dental erosion
Hyperactive bowel sounds
Bradycardia
83
When is someone admitted involuntarily to the hospital?
The family is unable to care for the client
When client needs medicine
The provider is a NP
The client is a danger to self or others
84
Parents took child off list for little league since child has terminal illness. What should nurse say?
"You never know. He could be ready for baseball by Spring."
"Why did you feel you needed to do that at this time?"
"It must be frustrating for ou to have to cancel an activity your son likes
"Baseball can be dangerous sport for children anyway"
85
A client on lithium has excessive urine output, course hand tremors, and muscular irritability? What is lithium level?
2.0
4.5
0.5
0.7
86
After 3 days of steroids, client becomes confused and does not know where they are. What is most likely the diagnosis?
Depression
Dementia
Delirium
Bipolar Disorder
87
Nurse is working on therapeutic relationship with angry client. Which is an appropriate nursing intervention?
Work on creating a friendship
Use humor to defuse anger
Sympathize with the client
Show respect that is not based on client's behavior
88
Which of the following is a negative symptom of schizophrenia?
Visual hallucinations
Flat affect
Persecutory delusions
Bizarre behavior
89
What would be expected of a client with conduct disorder?
Experiences frequent facial tics
Death of a father two months ago
Suspended from school multiple times
Adheres to routines
90
A nurse is caring for a client with anorexia nervosa. Which of the following interventions should the nurse take?
Compliment client for weight gain
Allow the client to eat at any time
Schedule regular weigh-in times
Provide privacy when friends visit
91
A client's lithium level is 1.0. What should the nurse do?
Hold medication and assess for toxicity
Administer the morning dose of lithium
Check the client's medication record to see if they have refused medicine
Prepare for a gastric lavage
92
What intervention method is beneficial to a client with borderline personality disorder?
Assertiveness training
Dialectical behavior therapy
Bibliotherapy
Flooding therapy
93
What is priority during the orientation (introductory) phase of the nurse-client relationship?
Review accomplishment of goals
Establish rapport and trust
Promote client insight
Attempt to find alternative placement for discharge
94
What following findings would the nurse expect with a client with autism?
Appropriate language development
Ritualistic behavior
Consistent limit testing
Short attention span
95
Nurse caring for client with dementia. Client says, "I want to go home and cook for my husband." Nurse should say
"This is a safe place for you to live."
"This is where you live now."
"Tell me what you like to cook for dinner."
"Your family said there is no one to care for you at home."
96
Therapeutic communication involves...Make sure to know different types of therapeutic communication techniques
Checking non-verbal communication
Ask why questions
Talking in a loud voice
Tell anxious patients not to worry
97
Which client would be appropriate for seclusion?
A client who manipulates other clients
A client who is intrusive
A client who is hostile and threatening staff and other clients
A client who is noncompliant with medicines
98
Client is becoming disruptive, causing others to complain. What is the nurse's best action?
Warn the client they will be restrained for verbal interuptions
Ignore the client's behavior
Set limits on the client's behavior
Ask the other clients how to manage this client
99
What can happen when a client takes an SSRI and St. John's Wort?
EPS
NMS
Serotonin Syndrome
No interactions between these medications

Final Exam Review Fall 2023 Flashcards | StudBud