What are hallmark symptoms of ADHD?

Inattention, hyperactivity, and impulsivity

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

Imbalanced nutrition less than body requirements related to starvation

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

Assess patient, hold medication, contact provider

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"

When is someone admitted involuntarily to the hospital?

The client is a danger to self or others

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

Liver functions such as AST/ALT

What would be expected of a client with conduct disorder?

Suspended from school multiple times

Which client would be appropriate for seclusion?

A client who is hostile and threatening staff and other clients

What would be considered a sign of tranference?

Client sees the nurse similarly to his own mother

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

The nurse should avoid touching during interactions if possible

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

Walk with client at a gradually slower pace

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

Client says, "No one cares. Life is not worth living." What shouls nurse say?

"I care about you and I am concerned that you feel so sad."

Regarding documentation in client record

Court considers not documented as not done

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

Admintster medication before the child has breakfast

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

Client has hallucinations. What action should the nurse take?

Ask the client direct questions about the hallucination

What is an important teaching point about sertaline?

This medication may cause an inability to orgasm

What is an appropriate instruction for a client on lithium?

Maintain normal salt and fluids in the diet

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

Investigate what situations precipitate anxiety

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

Administer the morning dose of lithium

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

"You must be feeling sad right now."

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?

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

Planning to give away his most prized possessions to his partner

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

Checking non-verbal communication

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

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

"Tell me what is concerning you."

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

Self-destructive behavior despite alternative interventions

Which of the following puts a client at risk for lithium toxicity?

The client runs 4 miles outdoors every afternoon without replensihing fluid

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Final Exam Review Summer 2023

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

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Questions 99

Answers

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

Final Exam Review Summer 2023 Flashcards | StudBud