A schizophrenic pt explains she has 20 kids & then points to the RN & says that shes one of them. The RN should respond:

“My name tag shows that I am a RN here.”

The RNs providing education on strategies for a safety plan for a victim of IPV. Which strategies should be included?

Plan an escape route to use if the abuser blocks the main exit., Establish a code with family and friends to signify violence., Have a bag ready that has extra clothes for self and children.

The RNs teaching a pt about abstinence therapy using Antabuse. What info should the pt acknowledge understanding?

Remain alcohol-free for 12 hours prior to the first dose.

Which statement tells the RN that the pt is using projection to deal w/ anxiety related to admission to the psych unit?

"I am here because the police thought I was doing something wrong."

Which diet selection by a depressed pt on an MAOI, indicates they understand dietary restrictions imposed by this med?

Pepperoni and cheese pizza, tossed salad, and soda.

A schizophrenic pt abruptly stopped his prescription for Geodon one month ago. Which questions should the RN ask the pt?

Do you hear sounds or voices that others do not hear?

An older pt w/ schizophrenia is found smearing feces on the bathroom walls. What action should the RN implement?

Escort the client out of the bathroom.

A schizophrenic pt on an M1 stopped taking his antipsychotics 1mo/ago. He continues to have poor judgment & refuses meds

Provide him w/ medication if he presents an imminent risk to self & others.

The RN is leading a group on the psych unit. Which approach should the RN use during working phase of group development?

Helping clients identify areas of problem in their lives.

An adolescents admitted 2 days ago for depression. When the RN tries to interview him, he becomes irritated & sarcastic.

Offer to play a game of cards with the client.

A pt w/ depression remains in bed all day, & declines activities. Which nursing problem is a priority for this pt?

Refusal to address nutritional needs.

A BPD pt has self-inflicted lacerations on the ABD. Which approach should the RN use when changing this pts dressing?

Perform the dressing change in a non-judgmental manner.

A pts admitted d/t a Tylenol OD. The pts told he has liver dmg. What is most important for the RN to include in DC plan?

Do not take any over-the-counter meds.

A pt reports hearing voices saying to get a knife & hurt himself. What is most important for RN to implement?

Assign the UAP to remain with the client at all times

When caring for an older pt, the RN observes bruises over legs, arms, back, and & areas. The RN suspects elder abuse...

RN should measure & document size, shape & color of the bruised areas

When giving a prescribed med, the pt tells the RN that he usually takes a different dosage. What should the RN do next?

Withhold the medication until the dosage can be confirmed.

A teen has lost 20 lbs in the last 3 months, & is admitted w/ ↓BP & ↑HR. She reports irregular menses & hair loss...

Initiated caloric and nutritional therapy should be included in POC

An older pt visits to obtain a renewal for Xanax. During assessment, they c/o of chest pain. What should RN do first?

Determine if Xanax was taken recently.

A pt presents w an erection that wont resolve. He reports he's taking Trazodone for insomnia. What should the RN to ask?

Have you taken any medications for erectile dysfunction?

A BPD pt who started lithium 5 days ago is c/o of excessive thirst. RN finds him drinking water from the bathroom sink.

Report the client’s serum lithium level to the HCP.

A v anxious pt is worried about the sun coming up tmrw. What is most important for the RN to implement during admission?

Assist the client in developing alternative coping skills.

A high schooler reveals to the RN that she's been vomiting for weight control. Which assessment should the RN focus on?

Frequency of bingeing and purging behaviors.

When preparing to administer to domestic violence screening tool to a female pt, which statement should the RN provide?

All pts are screened for domestic abuse because its common in our society.

Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview?

Describe self as a social drinker who drinks alcoholic beverages daily.

A pt says his jobs causing trouble in his life. He gets so angry driving to work, he considers “getting even” w drivers.

RN should respond, “sounds as if theres situations that make u feel angry”

A college student whos a victim of a car-jacking reports↑ anxiety. During interview, what should be highest priority?

Help the client feel safe to decrease anxiety.

Pt reports taking extra antianxiety meds bc“Im stressed out & just want sleep” Pt should be 1:1 based on what statement?

“I don’t want to walk. Nothing matters anymore.”

The RN helps a mentally disabled pt ambulate a day after appendectomy. The pt yells "Get out! I'll be up when Im ready!"

I'll be back in 30 min to help you get out of bed and walk around the room.

A pt w/ a BAL of 0.28 & closed TBI d/t fall is difficult to arouse. Which interventions priority for the RN in 1st 6hrs?

Place in a side-lying position with HOB elevated.

An HIV pt w/ hx of depression has ↑ rather than ↓ viral overload despite adherence to rx regimen. What should RN do 1st?

Ask the client if he takes St. John's Wort routinely.

A client is admitted w/ a depression dx . The nurse knows that which characteristic is mostindicative of depression?

A negative view of self and the future.

A MH worker is caring for a pt w ↑ aggressive behavior. Which action by MHW warrants immediate intervention by the RN?

Is attempting to physically restrain the patient.

A pts admitted for BPD & alcohol w/d, depressive phase. Based on which finding will the RN withhold the Clonidine?

Blood pressure readings of 90/62 mmHg to 92/58 mmHg.

A pt w/ dirty clothes & foul odor reports feeling scared d/t being stalked. What action is most important for the RN?

Offer the client a safe place to relax before interviewing her.

The RN leading a group session of adolescent pts gives a handout about anger mgmt. One pt is fidgety & interrupts peers.

Redirect him by encouraging him to read from the handout.

A pt reports ↓ interest in usual activities, a wish to be w/ their deceased SO, little appetite, & no sleep for days.

RN should explore the not sleeping for several days.

An elderly pt says she enjoys cooking, quilting & watching TV. 24hrs post-admit, the RN notes shes withdrawn & isolated.

Encourage pt to participate in a group quilting project.

After anorexia txment, a student asks the RN permission to work in the cafe as part of the school’s work-study program.

Recommend assignment to the receptionist’s office.

A pts brought in by her spouse. He reports she is reluctant to leave home d/t fear of crowds. Which problem applies?

Anxiety related to a real or perceived threat to physical integrity.

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Questions 99

Answers

1
A schizophrenic pt explains she has 20 kids & then points to the RN & says that shes one of them. The RN should respond:
“I can’t possibly be one if your children.”
“My name tag shows that I am a RN here.”
“I know that you don’t have 20 children.”
“Let’s go ask another RN is this is true.”
2
The RNs providing education on strategies for a safety plan for a victim of IPV. Which strategies should be included?
Plan an escape route to use if the abuser blocks the main exit.
Establish a code with family and friends to signify violence.
Take a self-defense course that retaliates the abuser with injury.
Have a bag ready that has extra clothes for self and children.
3
The RNs teaching a pt about abstinence therapy using Antabuse. What info should the pt acknowledge understanding?
Remain alcohol-free for 12 hours prior to the first dose.
Completely abstain from heroin or cocaine use.
Attend monthly meetings of alcoholics anonymous.
Admit to others that he is a substance user.
4
Which statement tells the RN that the pt is using projection to deal w/ anxiety related to admission to the psych unit?
"I want to be here because I know it is the best psychiatric facility."
"Don’t believe everything my family tells you, I am not crazy."
"I am here because the police thought I was doing something wrong."
"At least I hit the wall instead of hitting the psychiatric aide."
5
An angry pt yells, “My roommate is the most selfish, angry person. If he loses his temper, I'm going to punch him out!"
the RN recognizes Denial.
the RN recognizes Rationalization.
the RN recognizes Splitting.
the RN recognizes Projection.
6
Which diet selection by a depressed pt on an MAOI, indicates they understand dietary restrictions imposed by this med?
Hamburger, french fries, and chocolate milkshake.
Pepperoni and cheese pizza, tossed salad, and soda.
Liver and onions, broccoli, and decaffeinated coffee.
Roast beef, baked potato with butter, and iced tea.
7
A schizophrenic pt abruptly stopped his prescription for Geodon one month ago. Which questions should the RN ask the pt?
How many continuous hours do you sleep at night?
Have you lost interest in the things that you used to enjoy?
Do you hear sounds or voices that others do not hear?
Is your ability to think or concentrate decreased?
8
An older pt w/ schizophrenia is found smearing feces on the bathroom walls. What action should the RN implement?
Explain that the feces belong in the toilet.
Show the client how to clean the walls.
Escort the client out of the bathroom.
Assist the client to clean the walls.
9
A schizophrenic pt on an M1 stopped taking his antipsychotics 1mo/ago. He continues to have poor judgment & refuses meds
Encourage him to stay in the hospital so he does not have to be homeless.
Describe to him the treatment options provided at the community MH clinics.
Provide him w/ medication if he presents an imminent risk to self & others.
Administer a long-acting antipsychotic med so he can be DC'd to a shelter.
10
The RN is leading a group on the psych unit. Which approach should the RN use during working phase of group development?
Helping clients identify areas of problem in their lives.
Discussing ways to use new coping skills learned.
Establishing a rapport with group members.
Clarifying the nurse’s role and clients’ responsibilities.
11
An adolescents admitted 2 days ago for depression. When the RN tries to interview him, he becomes irritated & sarcastic.
Document the behavior in the chart.
Report the behavior to the next shift.
Plan to talk with the client the next day.
Offer to play a game of cards with the client.
12
The RN completes an assessment of a pt experiencing IPV. Which injury findings should the RN include in documentation?
A summary of the client’s feelings.
A general description.
A client’s significant other’s statement.
Photographs.
13
A pt w/ depression remains in bed all day, & declines activities. Which nursing problem is a priority for this pt?
Social isolation.
Low self-esteem.
Refusal to address nutritional needs.
Loss of interest in diversional activity.
14
A BPD pt has self-inflicted lacerations on the ABD. Which approach should the RN use when changing this pts dressing?
Ask in a non-threatening manner why the client cut own abdomen.
Request another staff member assist with the dressing change.
Perform the dressing change in a non-judgmental manner.
Provide detailed thorough explanations when cleansing wound.
15
A pts admitted d/t a Tylenol OD. The pts told he has liver dmg. What is most important for the RN to include in DC plan?
Call the crisis hotline if feeling lonely.
Do not take any over-the-counter meds.
Avoid exposure to large crowds.
Eat a high-carb, low-fat, low-protein diet.
16
A pt reports hearing voices saying to get a knife & hurt himself. What is most important for RN to implement?
Report behavior to his case workers so that the family can be notified
Don’t allow him to go into the kitchen until the hallucination has subsided
Assign the UAP to remain with the client at all times
Document the behavior in the client’s record and notify the HCP
17
When caring for an older pt, the RN observes bruises over legs, arms, back, and & areas. The RN suspects elder abuse...
RN should measure & document size, shape & color of the bruised areas
RN should ask the pt specific questions about someone causing the bruising
RN should question the family members & caregiver how the bruising occurred
RN should report family conversations & anger towards the pt when visiting
18
When giving a prescribed med, the pt tells the RN that he usually takes a different dosage. What should the RN do next?
Tell him to take the med then verify the dose at the next team meeting.
Explain to the client that the dosage has been changed.
Withhold the medication until the dosage can be confirmed.
Inform him that he may refuse the med and doc whether or not he takes it.
19
A teen has lost 20 lbs in the last 3 months, & is admitted w/ ↓BP & ↑HR. She reports irregular menses & hair loss...
Initiated caloric and nutritional therapy should be included in POC
Record of daily weights and graft trends should be included in POC
Evaluation of client for low self-esteem should be included in POC
Implemented behavioral modification therapy should be included in POC
20
An older pt visits to obtain a renewal for Xanax. During assessment, they c/o of chest pain. What should RN do first?
Refer the client to the cardiology unit.
Determine if Xanax was taken recently.
Assess the client for substance abuse.
Obtain the client Blood pressure.
21
A pt presents w an erection that wont resolve. He reports he's taking Trazodone for insomnia. What should the RN to ask?
Are you having any other sexual dysfunctions or problems?
Do you have a history of angina or high blood pressure?
Have you taken any medications for erectile dysfunction?
When was the last time you drank alcoholic beverage?
22
A BPD pt who started lithium 5 days ago is c/o of excessive thirst. RN finds him drinking water from the bathroom sink.
Tell the client that drinking from the faucet is not allowed.
No action is needed since polydipsia is a common side effect.
Encourage the client to suck on hard candy to relieve the symptoms.
Report the client’s serum lithium level to the HCP.
23
A v anxious pt is worried about the sun coming up tmrw. What is most important for the RN to implement during admission?
Assist the client in developing alternative coping skills.
Remain calm and use a matter-of-fact approach.
Ask the client why she is so anxious
Administer a PRN sedative to help relieve her anxiety.
24
A high schooler reveals to the RN that she's been vomiting for weight control. Which assessment should the RN focus on?
Perceptions of family and social relationships.
National percentile of weight and height.
School grades and extracurricular activities.
Frequency of bingeing and purging behaviors.
25
A pt arrives after police found her disoriented & confused. RN finds they're homeless & suspicious. Priority problem is:
Disturbed sensory perception.
Acute confusion.
Ineffective community coping
Self-care deficit.
26
When preparing to administer to domestic violence screening tool to a female pt, which statement should the RN provide?
All pts are screened for domestic abuse because its common in our society.
State law mandates that I ask if you are a victim of domestic violence.
The HCP provider needs to know if you are experiencing any domestic abuse.
If your partner is abusing you, I need to ask these questions.
27
Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview?
Reports difficulties with short term memory since traumatic brain injury.
Medical history includes that the client was recently sexually assaulted.
Describe self as a social drinker who drinks alcoholic beverages daily.
Client’s medication history includes the frequent use of antidepressants.
28
A pt says his jobs causing trouble in his life. He gets so angry driving to work, he considers “getting even” w drivers.
RN should respond, “Try not to let your anger cause you to act impulsively”
RN should respond, “sounds as if theres situations that make u feel angry”
RN should respond, “Expressing anger to a stranger could result as unsafe”
RN should respond, “Anger is contagious & results in major confrontation”
29
A pt who is known to abuse drugs is admitted. Which med should the RN anticipate giving to a pt exhibiting benzo w/d sx?
Perphenazine (Trilafon).
Isocarboxazid (Marplan).
Diphenhydramine (Benadryl).
Chlordiazepoxide (Librium).
30
Post MVC, a pts has mult facial fractures w/ high BAL. What PRN med should be given if they experience delirium tremens?
Lorazepam (Ativan) 2 mg IM.
Prochlorperazine (Compazine) 5 mg IM.
Chlorpromazine (Thorazine) 50 mg IM.
Hydromorphone (Dialuadid) 2 mg IM.
31
A pt believes that someone is trying to poison him. The nurse understands his delusions are most likely related to:
His phobic fear of food.
His low self-esteem.
His early childhood experiences involving authority issues.
His anger about being hospitalized.
32
A college student whos a victim of a car-jacking reports↑ anxiety. During interview, what should be highest priority?
Identify support systems in the community that may be helpful.
Encourage the client to verbalize anxiety related to event.
Ask the client to describe coping strategies that were helpful in the past.
Help the client feel safe to decrease anxiety.
33
Pt reports taking extra antianxiety meds bc“Im stressed out & just want sleep” Pt should be 1:1 based on what statement?
“What should I do? Nothing seems to help.”
“I have been so tired lately and needed to sleep.”
“I really think that I don’t need to be here.”
“I don’t want to walk. Nothing matters anymore.”
34
The RN helps a mentally disabled pt ambulate a day after appendectomy. The pt yells "Get out! I'll be up when Im ready!"
I'll be back in 30 min to help you get out of bed and walk around the room.
You must ambulate to avoid complications causing more discomfort.
Your HCP has prescribed ambulation on the first postoperative day.
I know how you feel. You're angry having to ambulate, but this'll help you.
35
A pt w/ a BAL of 0.28 & closed TBI d/t fall is difficult to arouse. Which interventions priority for the RN in 1st 6hrs?
Place in a side-lying position with HOB elevated.
Administer disulfiram (Antabuse) immediately.
Provide thiamine and folate supplements as prescribed.
Give lorazepam (Ativan) PRN for signs of withdrawal.
36
An HIV pt w/ hx of depression has ↑ rather than ↓ viral overload despite adherence to rx regimen. What should RN do 1st?
Ask the client if he takes St. John's Wort routinely.
Hold all antidepressant medications until further notice.
Determine if the client attends a support group weekly.
Have the client describe any recent changes in mood.
37
A schizophrenic pts demonstrating echolalia, which is becoming annoying to other pts. What is best for the RN to do?
Escort the client to his room.
Administer PRN sedative.
Isolate the client from the other clients.
Avoid recognizing the behavior.
38
The RNs doing an admit assessment of an underweight adolescent w/ a dx of depression. What finding requires call to HCP?
Body mass index of 21.
Potassium level of 2.9 mEq/dl.
Blood pressure of 110/70 mmHg.
WBC of 10,000mm^3.
39
A client is admitted w/ a depression dx . The nurse knows that which characteristic is mostindicative of depression?
Suspiciousness of others.
Grandiose ideation.
Self-destructive thoughts.
A negative view of self and the future.
40
A pt w/ delirium tremens is dehydrated & experiencing hallucinations. He has a bruised, swollen tongue & is confused.
Encourage oral fluids.
Apply ice to his tongue.
Keep the room dark.
Monitor vital signs.
41
A MH worker is caring for a pt w ↑ aggressive behavior. Which action by MHW warrants immediate intervention by the RN?
Is using a loud voice to talk to the client.
Remains at a distance of 4 feet from the client.
Is attempting to physically restrain the patient.
Tells the client to go to the quiet area of the unit.
42
A pts admitted for BPD & alcohol w/d, depressive phase. Based on which finding will the RN withhold the Clonidine?
Respiration rate of 24 breaths per minute.
Temperature of 99.5-99.7 F.
Pulse rate of 68-78 BPM.
Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
43
A pt w/ dirty clothes & foul odor reports feeling scared d/t being stalked. What action is most important for the RN?
Assure the client that the HCP will see her today.
Recommend that the client talk with a social worker.
Offer the client a safe place to relax before interviewing her.
Ask the client to describe why she is being stalked.
44
The RN leading a group session of adolescent pts gives a handout about anger mgmt. One pt is fidgety & interrupts peers.
Redirect him by encouraging him to read from the handout.
Encourage his peers to help involve him in the activity.
Give the client permission to leave and return in 10 minutes.
Explore the client’s feelings about his pets and home life.
45
A pt reports ↓ interest in usual activities, a wish to be w/ their deceased SO, little appetite, & no sleep for days.
RN should explore the lack of interest in usual activities.
RN should explore the eating very little.
RN should explore the not sleeping for several days.
RN should explore the wishing to be with spouse.
46
An elderly pt says she enjoys cooking, quilting & watching TV. 24hrs post-admit, the RN notes shes withdrawn & isolated.
Encourage pt to bake a cake for a resident's birthday.
Encourage pt to clean the unit kitchen cabinets.
Encourage pt to watch television in the activity room.
Encourage pt to participate in a group quilting project.
47
After anorexia txment, a student asks the RN permission to work in the cafe as part of the school’s work-study program.
Refer the student to a psychiatrist for further discussion.
Determine the parent’s opinion of the work assignment.
Suggest that student work in the athletic department.
Recommend assignment to the receptionist’s office.
48
A pt reports SOB & dizziness. The pt states, “I feel like Im going to die”. Which problem should the RN include in POC?
Social isolation.
Mood disturbance.
Altered thoughts.
Moderate anxiety.
49
A pts guarded, vaguely answers Qs, isolates in his room & opens door peeking into hall. What problem can RN anticipate?
Auditory hallucinations.
Visual hallucinations.
Delusions of persecution.
Excessive motor activity.
50
A female pt admitted to the MH unit starts to shout and scream at the RN. What is the best approach for the RN to take?
Ignore the client’s acting out behavior.
Stay quietly with the patient
Distract her by offering her finger foods.
Tell her that she is out of control.
51
A pts brought in by her spouse. He reports she is reluctant to leave home d/t fear of crowds. Which problem applies?
Risk for injury related to inability to communicate.
Risk-prone health behavior related to self-esteem assault.
Ineffective protection to guard self from internal or external threats.
Anxiety related to a real or perceived threat to physical integrity.
52
The RN gets report about a depressed pt who was in bed all weekend. The RN walks into their room & finds her in bed...
Assist the client to get out of bed and involved in an activity.
Explain that staff will check on the client every 30 minutes.
Monitor the client’s appetite and pattern of sleep.
Assess the client’s feelings about the hospital stay.
53
A pt runs around, crashing into/tossing chairs. When another pt objects, the pt states, “I'm the boss & do what I want!"
Risk for activity intolerance related to hyperactivity.
Disturbed personal identity related to grandiosity.
Risk for other related violence related to disruptive behavior.
Deficient diversional activity related to excess energy level.
54
A pt requests her spouse to sit in during admission. RN notes a discrepancy b/w their verbal & nonverbal communication.
Integrate the verbal and nonverbal messages and interpret them as one.
Ask the client’s husband to interpret the discrepancy.
Ignore the nonverbal behavior and focus on the client’s verbal messages.
Pay close attention and document the nonverbal messages.
55
While interviewing a pt, the RN takes notes for later. What is most accurate regarding note-taking during an interview?
Pts comfort level is increased when the RN breaks eye contact to take notes
Interview process is enhanced & allows the client to speak at a normal pace
RNs ability to directly observe the pts non-verbal communication is limited
Taking notes during an interview is a legal obligation of examining RN
56
A pt w agoraphobia starts desensitization w a therapist & the RN is reinforcing. Which intervention is priority for POC?
Progressively expose the client to larger crowds.
Encourage substitution of positive thoughts and negative ones.
Establish trust by providing a calm, safe environment.
Encourage deep breathing when anxiety escalates in a crowd.
57
The RN finds cmn bathroom has sputum on walls, urine in sink & floors, & the toilets clogged. What's the priority issue?
Infection control.
Medication non-compliance.
Acting out behaviors.
Number of bathroom facilities.
58
A pt refuses meds, disrupts activities, talks w nonsensical words & wanders into rooms. Why do they need constant obs?
Talks with nonsensical words.
Disrupts group activities.
Wanders into the clients rooms.
Refuses antipsychotic medications.
59
A pts attempted to shoot himself. He was divorced 1yr ago & lost his job 4 mo ago. What may be the source of depression?
Poor self-esteem.
Feelings of frustration.
A lack of intimate relationships.
A sense of loss
60
The RN accepts a transfer pt & understands that the pts easily distractible. The RN only has 15 min to talk to the pt.
the RN should obtain a history of substance use.
the RN should obtain a mental status examination.
the RN should obtain a motivation of treatment.
the RN should obtain medication compliance.
61
The RN suspects cigarette burns when assessing a 3yo. Which parental behavior provides support this may be child abuse?
Parents say child was burned in a house fire, incompatible w/ type of burn
Parents become anxious when RN suggests that child may need to be admitted
Parents' story of how burns occurred is different from the child's story
Parents dismiss severity of burns, saying they're small & aren't a problem
62
A pt w/ a hx of drug abuse reports she had a ♡ attack 4 years ago. Use of what substance puts her @ highest risk for MI?
Marijuana
Alcohol
Methamphetamine
Benzodiazepine
63
An adult w/ MDD suffers from psychomotor retardation, hypersomnia, & motivation. Which intervention is most effective?
Encourage the client to exercise.
Suggest that the client develop a list of pleasurable activities.
Teach the client to develop a plan for daily structured activities.
Provide education on methods to enhance sleep.
64
A bulimic pt w/ depression taking Phenelzine (Nardil) 90mg/day is admitted for uncontrolled HTN. What should they avoid?
Peperoni pizza.
Deep fried shrimp.
Beef trips with gravy.
Pan-seared catfish.
65
A shcizophrenic pt tells the RN that he is the son of God. Based on this statement, what should the RN include in POC?
Confront his delusion as not consistent with reality.
Schedule activity therapy twice a week.
Lead the client by his arm to the seclusion room.
Ensure the client’s environment is safe.
66
A pt states he has a 400+ IQ & he's married to a movie star but thinks his brother wants her sexually. Priority prob is:
Ineffective sexual patterns.
Impaired environmental interpretation.
Compromised family coping.
Disturbed sensory perception.
67
A schizophrenic pt w aggressive behavior & hallucinations hasnt been taking meds & insist foods poisoned/refuses to eat.
Rn should assure that all food served in the hospital is safe to eat.
RN should tell them irrational thinking is a symptom of schizophrenia.
RN should obtain an order for a tube feeding for the client.
RN should provide the client with food in unopened containers.
68
A schizophrenic pt w/ Risperdal med adjustment walks laterally contracted & states his body is turning into a monster.
the RN should medicate w/ the prescribed antipsychotic thioridazine
the RN should direct pt to OT to distract him from somatic complaints
the RN should offer the pt a prescribed PT hot pack for muscle spasms
the RN should give the prescribed anticholinergic benztropine for dystonia
69
A pt is receiving substitution therapy during w/drawal from benzos. Which expected outcome has the highest priority?
CNS stimulation will be reduced.
Client will not demonstrate cross addiction.
Client's level of consciousness will increase.
Co-dependent behaviors will be decreased.
70
An anxious pt is expressing a fear of people & open places. What's the most effective way for the RN to assist this pt?
Distract her whenever she expresses her discomfort about being with others.
Plan an outing within the first week of admission.
Confront her fears and discuss the possible causes of these fears.
Accompany her outside for an increasing amount of time each day.
71
A pts wife states he's been sleepwalking, can't remember who he is, & has multiple personalities. The behaviors are...
Panic disorder.
Obsessive-compulsive disorder.
Post-traumatic stress syndrome.
Dissociative disorder.
72
The RNs doing pt teaching for a pt w/ alcoholic cirrhosis. Which self-care measure should the RN emphasize for recovery?
Vitamin B and multivitamin supplements.
Diet with adequate calories and protein.
Support group meetings.
Alcohol abstinence.
73
A pt becomes agitated, pacing & shouts at staff. When PRN meds are offered the pt refuses & defiantly sits on the floor.
the RN should administer medication to chemically restrain the patient.
the RN should transport the pt to the seclusion room
the RN should take other clients in the area to the client lounge
the RN should quietly approach the client with additional staff members
74
A pt reports feeling depressed & had only 4hrs of sleep in the past 2 days. What should RN do in first 24hrs of txment?
Allow the client to rest and sleep
Ensure she attend groups addressing coping skills for dealing w/ depression
Begin planning for the clients discharge
Encourage verbalization of feelings
75
An antidepressant is prescribed for a pt whose only slept 4hrs in the past 2 days & ↓ weight of 9lbs w/in the last mo.
Understanding purpose of the med regimen should be achieved w/in 1st 3 days
Meeting scheduled appt w/ dietitian should be achieved w/in first 3 days
Sleeping at least 6 hours a night should be achieved w/in first 3 days
Describing reasons for hospitalization should be achieved w/in first 3 days
76
A pt has diarrhea, HA, & aches. She's febrile w no chills, & all labs are WNL. The pts sister calls her a hypochondriac.
RN should respond "I hear that your sister comments are over-whelming you."
RN should respond "Unless your sister has a medical education, ignore her."
RN should respond "Besides her comments, what in life is troubling you?"
RN should respond "Do you think it’s possible you're a hypochondriac?"
77
The RN is admitting a male pt who takes lithium carbonate (Eskalith) 2x/day. Which info should the RN report to the HCP?
Nausea and vomiting.
Five-pound weight gain
Short term memory loss.
Decreased affect.
78
A pts receiving benztropine mesylate (Cogentin) for drug-induced EPS. What finding indicates further evaluation of pt?
Presence of a dry mouth.
Decreasing hand tremors.
Decreased bowel movements.
Increased mouth movements.
79
A pt w/ hx of alcohol dependency has feelings of bugs crawling on his body. BP is 170/102, HR is 110, & BAL is 0mg/dL.
nurse should give Lorazepam (Ativan).
nurse should give Thiamine (Vitamin B1).
nurse should give Diphenhydramine (Benadryl).
nurse should give Haloperidol (Haldol).
80
The RN orients a depressed pt to her new room. She states, “seems strange that I dont have a TV.” How should RN respond?
“Sometimes clients feel like the TV is sending them messages.”
“Watching TV is a passive activity and we want you to be active.”
“It’s important to be out of your room and talking to others.”
“You can watch TV as much as you want outside of your room.”
81
A pts states, “I dont need to be here" & the TV is talking to her. RN should doc in which sec of the mental status exam?
Mood and affect.
Remote memory.
Level of concentration.
Insight and judgment.
82
A pt tells the RN he doesn't want the atypical antipsychotic, Olanzapine, bc of the s/e. What s/e are related to this?
Alerted liver function test.
Weight gain of 75 lbs.
Thoughts of wanting to hurt himself.
Frequent days with diarrhea.
83
Narcan is given to a pt after a SA w/ an OD of Vicodin. W/in 15 min, pt is A&O. What is highest priority at this time?
Obtain the client’s serum Vicodin level.
Observe the client for further narcotic effects.
Encourage the client to increase fluid intake.
Determine the client’s reason for attempting suicide.
84
An OPCD pt needs a cardiac cath. Before procedure, she keeps detailed notes of care shes receiving & reports them to RN.
Ask pt to explain why she is keeping a detailed record of her nursing care.
Teach pt strategies to control her obsessive-compulsive behavior.
Explain to pt that her behavior invades the rights of the nursing staff.
Encourage pt to express her feelings regarding the upcoming procedure.
85
A pt recently lost a loved one & says hes not interested in usual activities & hasnt slept. What should be in his POC?
Situational low self-esteem.
Sleep deprivation.
Risk for suicide.
Social isolation.
86
When starting POC for a pt following aspiration of a caustic material related to SA, which problem is highest priority?
Impaired comfort.
Ineffective coping.
Ineffective breathing pattern.
Risk for injury.
87
A child has a broken arm d/t possible abuse. When the RN gives him a shot, mom shouts "Dont touch him, you'll hurt him!"
The mother is suppressing her fear.
The mother is projecting her feelings onto the nurse.
The mother is regressing to an earlier behavior pattern.
The mother is sublimating her anger.
88
A pt reports, "Im always nervous now. Idk what to do. I haven't slept & have hardly eaten." What assessment can be made?
Inadequate social support.
Moderate levels of anxiety.
Altered thought processes.
Altered health maintenance.
89
A BPD pt comes from jail for assault. When asked to identify his reason for the assault he states, "bc he made me mad!"
Pt should verbalize feelings when anger occurs.
Pt should recognize consequences for behaviors exhibited.
Pt should control impulsive actions toward self and others.
Pt should outline methods for managing anger.
90
A RN is prepping the environment to interview a new pt on the unit. Which setting is the best outcome for the interview?
Sit within two feet of the client to enhance level of safety and security.
Position table between the client and the RN for extra personal space.
Reduce the noise level in the room by turning off the television and radio.
Dim the lights in the room to help the patient feel calm.
91
An employees been told that her kid was in an MVA & is hospitalized. She states, “I cant believe it. What should I do?"
RN should respond, "How serious was the collision?"
RN should respond, "What do you think you should do?"
RN should respond, "Tell me what you think should happen."
RN should call for transportation to the hospital.
92
A pt being treated w/ Lithium for manic depression begins to develop N/V/D & drowsiness. What action should the RN take?
Record the symptoms and continue medication as prescribed.
Hold the med and refuse to administer additional amounts of the drug.
Notify the physician immediately and force fluids.
Prior to giving the next dose, notify the physician of the symptoms.
93
A pushed RNs very angry & swings at the other RN. They're referred to the staff psych RN. What hx is related to his rxn?
Tortured animals as a child.
Is worried about losing his job to a woman.
Hates to be touched by anyone.
Was physically abused by his mother.
94
A pts been 2 wks hospitalized w/ chronic paranoia & states someone is trying to steal his stuff. What will RN implement?
Ignore the client's paranoid ideation to extinguish these behaviors.
Encourage him to actively participate in assigned activities on the unit.
Place a lock on the client's closet.
Explain to the client that his suspicions are false.
95
A mom of an infant w/ disabilities admits how depressed she is realizing her child will never achieve normal milestones.
RN should determine if she has other children who do not have disabilities
RN should ask if she has ever thought about harming herself or her child
RN should encourage the mother to write thoughts and feelings in journal
RN should reassure her they'll achieve some growth & development milestones
96
The RN receives report that a pts scheduled for ECT in the morning. What should the RN implement the evening before?
Give the client an enema at bedtime.
Keep the client NPO after midnight.
Implement elopement precautions.
Hold all bedtime medications.
97
Which nursing actions are likely to help promote the self-esteem of a male client with modern depression?
Encourage the client to engage in recreational therapy.
Ask the client what his long-term goals are.
Include the client in determining treatment protocol.
Provide opportunities for the client to discuss his concerns.
98
RNs preparing meds for a BPD pt & notices they DC'd antipsychotic meds for several days. Which meds should also be DC'd?
Alprazolam (Xanax).
Lithium. (Lithotabs)
Magnesium (Milk of Magnesia).
Benztropine (Cogentin).
99
After surgery, a pt w/ antisocial personality DO requests a specific RN & is belligerent when another RN is assigned.
Reassure the client that his request will be met whenever possible.
Advise the client that assignments are not based on the client’s request.
Ask the client to explain why he constantly requests the RN.
Encourage the client to verbalize his feelings about the RN.

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