A nurse on an acute unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing action should the nurse include in the client’s plan of care?

Implement one on one observation during meals

The nurse recognizes that patients with schizophrenia suffer from cognitive symptoms. Which of the following demonstrates these symptoms?

Cognitive symptoms inhibit them to utilize judgment

The nurse in the unit is discussing legal terms. The nurse described that defamation of character occurs when a provider

makes a false statement that causes some degree of harm to an individual. She is aware that by doing this should be charged with, which of the following?

slander

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. The newly licensed nurse sees the client exhibiting lip smacking, tongue fasciculations. The newly licensed nurse understands that she is documenting:

tardive dyskinesia

The nurse is doing a physical assessment on the client that was recently admitted to the behavioral unit. Which assessment finding is most associated with bulimia nervosa?

prominent parotid glands

When talking with a patient diagnosed with schizophrenia, the healthcare provider notes the patient continually states, "I'm

the man with a plan,yes I am." The healthcare provider will document this behavior as which of the following?

Clang associations

A nurse is conducting an in-service on crisis management. Which of the following would be an example of a client experiencing a maturational crisis?

death of mother

The nurse in the unit is doing discharge instructions with a bipolar client. When the nurse is teaching the client in regard to lithium, she ensures that patient verbalizes:

"I need to take lithium with food."

A nurse is monitoring a client who has schizophrenia ad is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? Select all that apply

rigidity

Hyperpyrexia

Fluctuations in blood pressure

The nurse educator is teaching new nurse's regarding Alzheimer's disease. Which of the following symptoms can the patient display? Select all that apply.

agnosia

apraxia

aphasia

A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following anxiety levels is the client exhibiting?

severe

A nurse is assessing a client who is receiving treatment with Risperidone. Some of the findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that, which of the following adverse effects may be occurring?

Neuroleptic malignant syndrome

A nurse is teaching a client who has a new prescription for disulfiram to treat alcohol use disorder. Which of the following statements by the client indicates an understanding o the teaching?

"I should check the labels of my skin-care products, medications, and food for alcohol."

The health care provider has prescribed valproic acid (Depakene) for a client with bipolar disorder who has achieved limited success with lithiumcarbonate (Lithane). The nurse should instruct the client about which of the following?

Tachycardia and upset stomach are common side effects. Follow-up blood test such as BUN and Creatinine are always necessary.

Follow-up blood test such as LFT's are necessary while on this medication

A client is experiencing depression; another client is diagnosed with cyclothemia. The nursing student understands that these clients are exhibiting similar characteristics. Select all that apply?

Avolution
Anergia
Anhedonia
Aloof

A nurse is caring for a client who is taking amitriptyline. The nurse should monitor for which of the following adverse effects?

Orthostatic hypotension

During group therapy, a client diagnosed with somatization pain disorder monopolizes the group by discussing back pain. Which nursing statement is an appropriate response in this situation?

"I can tell this is bothering you. Let's briefly discuss this further after group."

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply.)

Hypertension Fever Seizures Restlessness

A nurse is conducting a class for group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching?

A non-suicide contract decreases the client's risk for suicide

The nurse is checking the laboratory values for a client admitted with anorexia nervosa. Which of the following are common laboratory findings associated with anorexia?

Hypokalemia, hypoalbuminemia, and increase cholesterol level.

The nurse is receiving a client to the behavioral unit with a personality disorder. The nurse will document which of the following as characteristics of an Antisocial personality?

Lack of empathy, manipulative, and charming.

The nurse in the behavioral unit is performing a physical assessment of a client with Anorexia. Which physical assessment finding is most associated with Anorexia Nervosa? (Select all that apply)

Yellowed skin

acrocyanosis

lanugo

mottled cool extremities

The nurse administers each of the following medications to various clients on the behavioral health unit. The nurse knows that the client who should be most carefully monitored for fluid and electrolyte imbalance is the one receiving:

lithium

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts?

False imprisonment

A nurse is conducting an in-service on crisis management. Which of the following would be an example of a client experiencing adventitious crisis?

intended plane crash and riots

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?

The client had a motor vehicle crash last year and sustained a head injury.

The nurse is working in the emergency department and is conducting an assessment on a client with opioid intoxication. Which of the following is the nurse documenting?

Slurred speech, impaired judgement and memory

A nurse is teaching a client who has agoraphobia about systematic desensitization. Which of the following comments should the nurse include in the teaching?

"You will slowly be exposed to increasing levels of public spaces."

A nurse in an acute mental health facility is planning care for a client who has Obsessive Compulsive Disorder (OCD). Which of the following actions should the nurse include in the plan of care?

Instruct the client to practice thought stopping

A nurse is assessing a client who has schizophrenia. Which of the following statements by the client should the nurse recognize as an erotomaniac delusion?

"I have only met Jenny twice, but I know she loves me."

The nurse is working in the detox unit. She is aware that which of the following are consistent with delirium? (Select all that apply).

A medical emergency Reversible acute onset

A nurse is caring for a client who has schizophrenia .The client sates" Aliens came into my room last night and took a sample of my blood." Which of the following should the nurse make?

"Do you mean to say a laboratory technician drew your blood last night."

The nurse is working in the behavioral unit. The nurse is aware that which of the following demonstrates the ethical principle of beneficence?

Providing frequent updates to the family of a patient currently in surgery.

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. The nurse should identify that these manifestations indicate which of the following adverse effects of haloperidol?

Tardive dyskinesia

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder?

Death of a child 2 months ago.

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?

If suspicion of abuse exists then reporting is mandatory."

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and flat affect. The nurse should anticipate a prescription of which of the following medications?

Risperidone

A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else". This statement reflects, which of the following defense mechanisms?

Alturism

A nurse is planning care for a client who has completed detoxification from opioids abuse disorder. The nurse should plan to teach about which of the following medications?

Naltrexone

During admission, the client describes feeling depressed, "for as long as I can remember." The nurse understands this symptom is indicative of what type of depression?

Major depressive disorder

During a home visit, a client who is 75 years of age tells the community health nurse, "Lately I'm getting forgetful about things. For one thing, I cannot remember names. Do you think I am getting Alzheimer disease?" Which of the following responses by the nurse is the most therapeutic?

"Tell me more about your forgetfulness. It isn't usual for forgetfulness to occur."

A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

"I will assist you in getting out of bed and getting dressed."

A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective?

The client reports techniques she uses to promote sleep.

The nurse is reviewing the medical record and noticed that the clients history have under subjective data: "My throat is painful". From the list below, Which medication is most likely to cause fatal agranulocytosis?

Clozapine

A client with a diagnosis of borderline personality disorder is admitted with self-inflicted scratches on her forearms. The nurse is assessing the client's suicidal plan. It is important to assess which of the following? Select all that apply.

Presence of suicidal plan.

"Expressions that everything will be well soon"

Access to the means for enforcing the suicidal plan.

Self-harm behaviors of razor blade cuts.

Expressions that her life "isn't worth anything."

Which therapeutic communication technique is being used in the following example: Client: Every time I get angry, I wind up getting into a fistfight with my wife." Nurse: You express your anger through physical violence directed at you family."

Restating

A client diagnosed with schizophrenia is experiencing anhedonia. The nurse understands that the client is exhibiting which of the following?

Lack of pleasure a negative symptom

A nurse is providing teaching to a client who has a new prescription form disulfiram for the management of alcohol dependence. Which of the following dietary items should the nurse instruct the client to avoid?

Pure vanilla extract

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute
care nurses indicates a need for clarification?

"I have heard that abusers think of themselves as important and have high self esteem.

The nurse taking care of the schizophrenic client in the unit and hears the client having verbigeration. Which of the following will you point out?

The hall and tall the ball, the hall and tall the ball

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates word salad?

"Option, contrary, moose, allergic."

A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?

Ideas of reference

A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication?

Offering advice

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?

Dilated pupils, chest pain.

A client is admitted with diagnosis of dementia (Alzheimer type). Which nursing intervention is the priority when caring for the client?

Ensure environment is safe to prevent injury.

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply).

Attempts to convince other clients to give him their belongings.

Blames others for his past and current problems.

A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis?

"She won't let me take the trash from her room. I'm concerned about what she has in there."

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

"I may feel drowsy for a few weeks after starting this medication."

A nurse is instructing a client on toxicity of using lithium carbonate for their bipolar disorder. The nurse provides the following teaching that lithium may cause polyuria and muscle weakness. Which other sign of toxicity should the nurse include in the teaching?

Tinnitus of the ears is a possible indication of early lithium toxicity.

A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective?

The client reports techniques she uses to promote sleep.

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check for? (Select all that apply).

Sodium level

Thyroid hormone assay

Creatinine level

The nurse is receiving a client to the behavioral unit with a personality disorder. The nurse will document which of the following as characteristics of a Narcissistic personality?

Arrogance need for consistent admiration, self-importance.

A nurse is conducting an in-service on crisis management. Which of the following would be an example of a client experiencing a situational/adventitious crisis?

Rape and losing a job

A nurse is assessing a client who experienced a sexual assault 3 months ago. Which of the following findings should the nurse report to the provider as an indication of rape-trauma syndrome?

Report of intense guilt

The nurse is teaching a client being discharge home with a prescription of Phenelzine. Which of the following interactions will the nurse be mostly concerned when discussing a meal plan with the client?

Avocados

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?

Ensure that the client swallows medication.

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?

"I am here to provide care and cannot accept this form you."

An 18-year-old woman is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa. A cognitive behavioral approach is used as part of her treatment plan. A nurse understands that the purpose of this approach is to:

Help the client identify and examine dysfunctional thoughts and beliefs

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first?

Explore what the voices are saying to the client.

A client with schizophrenia is unable to get out of bed and get dressed unless the nurse prompts him to do so. This is an example of which behavior?

Avolition

A nurse is planning care for the termination phase of a nurse- client relationship. Which of the following actions should the nurse include in the
plan of care?

Discussing ways to use new behaviors.

A client is coming into the ER with signs of alcohol withdrawal. Which of the following medications would the nurse anticipate to administer, as per physicians orders?

Chlordiaxepoxide

A nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Before discharge, which of the following should the nurse teach the client?

Get up slowly when changing positions

A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which type of crisis is the family experiencing?

Both maturational and situational

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?

"Stop screaming and walk with me outside."