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

What are hallmark symptoms of ADHD?

Inattention, hyperactivity, and impulsivity

Client is becoming disruptive, causing others to complain. What is the nurse's best action?

Set limits on the client's behavior

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

Discuss need to take medication even when symptoms improve

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

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

"Tell me what has been happening lately"

What should you teach a client about disulfiram?

Taking this medication with alcohol is dangerous

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

"Tell me what is concerning you."

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

Imbalanced nutrition less than body requirements related to starvation

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."

A nurse is teaching about ECT. What of the following should be included?

Temporary memory loss is the most common adverse effect

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

Maintain contact with the client and assure client's safety

What is an important teaching point about sertaline?

This medication may cause an inability to orgasm

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

"You must be feeling sad right now."

What would be expected of a client with conduct disorder?

Suspended from school multiple times

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

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

The client runs 4 miles outdoors every afternoon without replensihing fluid

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."

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

Investigate what situations precipitate anxiety

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

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

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

Promote appropriate behavior during therapy sessions

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

Admintster medication before the child has breakfast

What would be considered a sign of tranference?

Client sees the nurse similarly to his own mother

Which of the following demonstrates autonomy

Supporting the client wishes to refuse prescribed medication

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.

A nurse is caring for a client with anorexia nervosa. Which of the following interventions should the nurse take?

Schedule regular weigh-in times

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

Ground beef patty and mashed potatoes

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Final Exam Review Spring 2025

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

Final Exam Review Spring 2025 Flashcards | StudBud