NU401 Exam 3 Questions And Accurate Answers
A nurse discovers a client's suicide note that identifies the time, place, and method to
complete suicide. What is the priority nursing intervention, and why?
1. The client is upset with the discovery of the plan and should be medicated with
lorazepam (Ativan) prn.
2. The client must be put on room restrictions because threatening self or others is an
attempt to manipulate the staff.
3. The client must be put on one-on-one suicide precautions because specific plans are
likely to be followed by an attempt.
4. Call an emergency treatment team meeting because the client's threat needs
attention - Answer 3
When creating a care plan for a suicidal client, which of the following appropriately
stated outcome should be the nurse's priority?
1. The client will not physically harm self.
2. The client will be able to express hope for the future by day three.
3. The client will be able to establish a trusting relationship with the nurse.
4. The client will not be injured during his hospitalization. - Answer 4
A nurse administers 100% oxygen to a client before, during, and after ECT treatment.
For what reason does the nurse provide this intervention?
1. To prevent anoxia-induced hypertension and increased intracranial pressure.
2. To prevent electrically induced muscle contractions that cause hypotension,
bradycardia, and decreased respiration.
3. To prevent anoxia caused by medication-induced paralysis of respiratory muscles.
4. To prevent blocked airway, resulting from seizure activity. - Answer 3
Immediately after ECT, the nurse should place the
,client in which of the following positions?
1. On his or her side, to prevent aspiration
2. In high Fowlers position, to prevent increased intracranial pressure
3. In Trendelenburgs position, to promote blood flow to vital organs
4. In prone position, to prevent airway blockage - Answer 1
A client is diagnosed with major depressive episode. Which nursing diagnosis should a
nurse
assign to this client, to address a behavioral symptom of this disorder?
1. Altered communication R/T feelings of worthlessness AEB anhedonia
2. Social isolation R/T poor self-esteem AEB secluding self in room
3. Altered thought processes R/T hopelessness AEB persecutory delusions
4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia -
Answer 2
A client who has been diagnosed with major depressive episode reports that he hears
voices that tell him to harm himself. Which should be the nurse priority intervention at
this time?
1. Obtain an order for locked seclusion until client is no longer suicidal
2. Initiate 15 minute checks for safety
3. Place client on one-to-one observation while continuing to monitor for suicidal
ideations.
4. Encourage client to express feelings related to suicide. -Answer 3
A nurse is assessing a client suspected of having the diagnosis of major depressive
episode.
Which client symptom would rule out this diagnosis?
1. The client is disheveled and malodorous.
2. The client refuses to interact with others and isolates self in room.
,3. The client is unable to feel any pleasure.
4. The client has maxed-out charge cards and exhibits promiscuous behaviors. - Answer
4
A client who has a history of a suicide attempt has been taking fluoxetine (Prozac) for
four weeks.
The client suddenly presents in bright affect, rates mood at 9 out of 10 on the mood and
is much more
talkative. At this point, which is the nurse's first action?
1. Provide the client with off-unit privileges as positive reinforcement.
2. Encourage the client to relate mood improvement in group.
3. Increase the level of this client's suicide precautions.
4. Request the psychiatrist to reconsider current medication regimen. - Answer 3
A nurse is interpreting the laboratory information of a client suspected of having the
diagnosis of major
depressive episode. Which of the following lab values would rule out this diagnosis?
1. TSH level of 25 U/mL
2. Potassium (K+) level of 4.2 mEq/L
3. Sodium (Na+) level of 140 mEq/L
4. Calcium (Ca2+) level of 9.5 mg/dL - Answer 1
The depressed client tells the nurse he has encountered divorce, loss of job, loss of
family support, and cocaine abuse. Which theoretical principle does the development of
this client's depressive symptoms most suggests?
1. Psychoanalytic theory proposes that depression occurs due to negative perceptions.
2. Object-loss theory says depression develops due to overprotection.
3. Learning theory states that depression occurs due to repeated failures.
4. Cognitive theory regards depression as a product of anger turned inward. - Answer 3
, What is the rationale for a nurse to conduct a thorough physical health assessment on a
client
admitted with the diagnosis of major depressive episode?
1. The attention associated with the examination is helpful in reducing social isolation.
2. Depression can produce somatic symptoms that may mask actual physical illnesses.
3. Medical complications are expected due to antidepressant treatment
4. Depressed clients tend to avoid discussing physical health issues and medical
concerns are not addressed. -Answer 2
A nurse is formulating a plan of care for a depressed client, age 13. Which of the
following medications is FDA approved for treating depression in adolescents?
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Citalopram (Celexa)
4. Escitalopram (Lexipro) -Answer 4
A nurse admits an older client with memory loss confused thinking and apathy. A
psychiatrist suspects a depressive disorder. What is the rationale for performing a
mini-mental
status exam?
1. To rule out bipolar disorder
2. To rule out schizophrenia
3. To rule out neurocognitive disorder
4. To rule out personality disorder - Answer 3
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A
health-care
provider orders amitriptyline (Elavil) for the client. Which intervention, related to this
A nurse discovers a client's suicide note that identifies the time, place, and method to
complete suicide. What is the priority nursing intervention, and why?
1. The client is upset with the discovery of the plan and should be medicated with
lorazepam (Ativan) prn.
2. The client must be put on room restrictions because threatening self or others is an
attempt to manipulate the staff.
3. The client must be put on one-on-one suicide precautions because specific plans are
likely to be followed by an attempt.
4. Call an emergency treatment team meeting because the client's threat needs
attention - Answer 3
When creating a care plan for a suicidal client, which of the following appropriately
stated outcome should be the nurse's priority?
1. The client will not physically harm self.
2. The client will be able to express hope for the future by day three.
3. The client will be able to establish a trusting relationship with the nurse.
4. The client will not be injured during his hospitalization. - Answer 4
A nurse administers 100% oxygen to a client before, during, and after ECT treatment.
For what reason does the nurse provide this intervention?
1. To prevent anoxia-induced hypertension and increased intracranial pressure.
2. To prevent electrically induced muscle contractions that cause hypotension,
bradycardia, and decreased respiration.
3. To prevent anoxia caused by medication-induced paralysis of respiratory muscles.
4. To prevent blocked airway, resulting from seizure activity. - Answer 3
Immediately after ECT, the nurse should place the
,client in which of the following positions?
1. On his or her side, to prevent aspiration
2. In high Fowlers position, to prevent increased intracranial pressure
3. In Trendelenburgs position, to promote blood flow to vital organs
4. In prone position, to prevent airway blockage - Answer 1
A client is diagnosed with major depressive episode. Which nursing diagnosis should a
nurse
assign to this client, to address a behavioral symptom of this disorder?
1. Altered communication R/T feelings of worthlessness AEB anhedonia
2. Social isolation R/T poor self-esteem AEB secluding self in room
3. Altered thought processes R/T hopelessness AEB persecutory delusions
4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia -
Answer 2
A client who has been diagnosed with major depressive episode reports that he hears
voices that tell him to harm himself. Which should be the nurse priority intervention at
this time?
1. Obtain an order for locked seclusion until client is no longer suicidal
2. Initiate 15 minute checks for safety
3. Place client on one-to-one observation while continuing to monitor for suicidal
ideations.
4. Encourage client to express feelings related to suicide. -Answer 3
A nurse is assessing a client suspected of having the diagnosis of major depressive
episode.
Which client symptom would rule out this diagnosis?
1. The client is disheveled and malodorous.
2. The client refuses to interact with others and isolates self in room.
,3. The client is unable to feel any pleasure.
4. The client has maxed-out charge cards and exhibits promiscuous behaviors. - Answer
4
A client who has a history of a suicide attempt has been taking fluoxetine (Prozac) for
four weeks.
The client suddenly presents in bright affect, rates mood at 9 out of 10 on the mood and
is much more
talkative. At this point, which is the nurse's first action?
1. Provide the client with off-unit privileges as positive reinforcement.
2. Encourage the client to relate mood improvement in group.
3. Increase the level of this client's suicide precautions.
4. Request the psychiatrist to reconsider current medication regimen. - Answer 3
A nurse is interpreting the laboratory information of a client suspected of having the
diagnosis of major
depressive episode. Which of the following lab values would rule out this diagnosis?
1. TSH level of 25 U/mL
2. Potassium (K+) level of 4.2 mEq/L
3. Sodium (Na+) level of 140 mEq/L
4. Calcium (Ca2+) level of 9.5 mg/dL - Answer 1
The depressed client tells the nurse he has encountered divorce, loss of job, loss of
family support, and cocaine abuse. Which theoretical principle does the development of
this client's depressive symptoms most suggests?
1. Psychoanalytic theory proposes that depression occurs due to negative perceptions.
2. Object-loss theory says depression develops due to overprotection.
3. Learning theory states that depression occurs due to repeated failures.
4. Cognitive theory regards depression as a product of anger turned inward. - Answer 3
, What is the rationale for a nurse to conduct a thorough physical health assessment on a
client
admitted with the diagnosis of major depressive episode?
1. The attention associated with the examination is helpful in reducing social isolation.
2. Depression can produce somatic symptoms that may mask actual physical illnesses.
3. Medical complications are expected due to antidepressant treatment
4. Depressed clients tend to avoid discussing physical health issues and medical
concerns are not addressed. -Answer 2
A nurse is formulating a plan of care for a depressed client, age 13. Which of the
following medications is FDA approved for treating depression in adolescents?
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Citalopram (Celexa)
4. Escitalopram (Lexipro) -Answer 4
A nurse admits an older client with memory loss confused thinking and apathy. A
psychiatrist suspects a depressive disorder. What is the rationale for performing a
mini-mental
status exam?
1. To rule out bipolar disorder
2. To rule out schizophrenia
3. To rule out neurocognitive disorder
4. To rule out personality disorder - Answer 3
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A
health-care
provider orders amitriptyline (Elavil) for the client. Which intervention, related to this
