1. A client with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priority for this
client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem.
C. Refusal to address nutritional needs.
2. The RN is preparing medications for a client with bipolar disorder and
notices that the client discontinued antipsychotic medication for
several days. Which medication should also be Discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
b. Benzotropine (Cogentin).
3. The RN is teaching a client about the initiation of the prescribed
abstinence therapy using disulfiram (Antabuse). What information
should the client acknowledge understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user.
B. Remain alcohol free for 12 hours prior to the first dose.
4. A male client with schizophrenia is admitted to the mental health unit
after abruptly stopping his prescription for ziprasidone (Geodon) one
month ago. Which question is most important for the RN to ask the
client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear?
, D. Do you hear sounds or voices that others do not hear?
5. A female client requests that her husband be allowed to stay in the
room during the admission assessment. When interviewing the client,
the RN notes a discrepancy between the client's verbal and nonverbal
communication. What action does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client's husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client's verbal
messages.
D. Integrate the verbal and nonverbal messages and interpret them as
one.
A. Pay close attention and document the nonverbal messages.
6. A male client approaches the RN with an angry expression on his face
and raises his voice, saying "My roommate is the most selfish, self-
centered, angry person I have ever met. If he loses his temper one
more time with me, I am going to punch him out!" The RN recognizes
that the client is using which defense mechanism?
A. Denial.
B. Projection.
C. Rationalization.
D. Splitting.
B. Projection.
7. A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by
the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loud voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
A. Is attempting to physically restrain the patient.
8. A client on the mental health unit is becoming more agitated, shouting
at the staff, and pacing in the hallway. When the PRN medication is
offered, the client refuses the medication and defiantly sits on the floor
in the middle of the unit hallway. What nursing intervention should the
RN implement first?
A. Transport of the client to the seclusion room.
, B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient.
C. Take other clients in the area to the client lounge.
9. A male client with bipolar disorder who began taking lithium carbonate
five days ago is complaining of excessive thirst, and the RN finds him
attempting to drink water from the bathroom sink faucet. Which
intervention should the RN implement?
A. Report the client's serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
A. Report the client's serum lithium level to the HCP.
10. During an annual physical by the occupational RN working in a
corporate clinic, a male employee tells the RN that is high-stress job is
causing trouble in his personal life. He further explains that he often
gets so angry while driving to and from work that he has considered
"getting even" with other drivers. How should the RN respond?
A. "Anger is contagious and could result in major confrontation."
B. "Try not to let your anger cause you to act impulsively."
C. "Expressing your anger to a stranger could result in an unsafe
situation."
D. "It sounds as if there are many situations that make you feel angry."
D. "It sounds as if there are many situations that make you feel angry."
11. A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the RN is reinforcing the
process. Which intervention has the highest priority for this client's
plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd.
B. Establish trust by providing a calm, safe environment.
12. Which nursing actions are likely to help promote the self-esteem
of a male client with modern depression? SATA
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
, C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
A. Ask the client what his long term goals are.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
13. A male client is admitted to the psychiatric unit for recurrent
negative symptoms of chronic schizophrenia and medication
adjustment of Risperidone (Risperdal). When the client walks to the
nurse's station in a laterally contracted position, he states that
something has made his body contort into a monster. What action
should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine
(Mellaril).
B. Offer the client a prescribed physical therapy hot pack for muscle
spasms.
C. Direct client to occupational therapy to distract him from somatic
complaints.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for
dystonia.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for
dystonia.
14. A client is admitted to the mental health unit and reports taking
extra anti-anxiety medication because, "I'm so stressed out. I just want
to go to sleep." The RN should plan one-on-one observation of the
client based on which statement?
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore."
D. "I don't want to walk. Nothing matters anymore."
15. A male hospital employee is pushed out the way by a female
employee because of an oncoming gurney. The pushed employee
becomes very angry and swings at the female employee. Both
employees are referred for counseling with the staff psychiatric RN.
Which factor in the pushed employee's history is most related to the
reaction that occurred?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller BESTNURSING. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
