A client's lithium level is 1.0. What should the nurse do?

Administer the morning dose of lithium

Therapeutic communication involves...Make sure to know different types of therapeutic communication techniques

Checking non-verbal communication

Client with anxiety is pacing up and down halls. What should nurse do?

Walk with client at a gradually slower pace

What is true regarding reporting child abuse?

If suspicion of abuse if present, reporting is mandatory

What is an important teaching point about sertaline?

This medication may cause an inability to orgasm

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

Maintain contact with the client and assure client's safety

What is an appropriate instruction for a client on lithium?

Maintain normal salt and fluids in the diet

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

"Tell me what has been happening lately"

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

I need to make sure the potential victim is warned

A client is on methylphenidate. Which information should the nurse provide?

Admintster medication before the child has breakfast

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"

When can the nurse break patient confidentiality?

Providers are required to warn individuals if the client threatens them

What would be considered a sign of tranference?

Client sees the nurse similarly to his own mother

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?

What should you teach about sertraline? Know major teaching points of SSRIs

Discuss need to take medication even when symptoms improve

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 caring for client with dementia. Client says, "I want to go home and cook for my husband." Nurse should say

"Tell me what you like to cook for dinner."

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

Ground beef patty and mashed potatoes

Client say, "I am tired of feeling this way. Nothing ever goes right." What is most appropriate nursing response?

"You are feeling sad right now and it is a hard time."

Nurse is working on therapeutic relationship with angry client. Which is an appropriate nursing intervention?

Show respect that is not based on client's behavior

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

place client on 1 to 1 observation

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

Self-destructive behavior despite alternative interventions

Spouse who visited client states, "I am worried about my husband." What should nurse say?

"Tell me what is concerning you."

Parents took child off list for little league since child has terminal illness. What should nurse say?

"It must be frustrating for ou to have to cancel an activity your son likes

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

Client has a prescription for valproate. What lab needs to be monitored?

Liver functions such as AST/ALT

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

Give positive feedback when assertive with staff or clients

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

What is the priority intervention for a client with histrionic personality disorder?

Promote appropriate behavior during therapy sessions

Which of the following demonstrates autonomy

Supporting the client wishes to refuse prescribed medication

What would be expected of a client with conduct disorder?

Suspended from school multiple times

What are hallmark symptoms of ADHD?

Inattention, hyperactivity, and impulsivity

Client says, "I am thinking about ending it all." What should nurse respond?

"You must be feeling sad right now."

studbud

Final Exam Review Fall 2023

99 termsStudBud Administration91 plays

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

Flashcards99 cardsFPractice quizPHost liveL

Questions 99

Answers

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

Final Exam Review Fall 2023 Flashcards | StudBud