PHARM
The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse would suspect that the client has suddenly discontinued taking which prescribed medication?
A. Sertraline
B. Diazepam
C. Fluoxetine
D. Haloperidol
Correct answer: B
Rationale:
The only benzodiazepine presented in the options is diazepam. Benzodiazepines are effective only when used for short-term therapy. Short-acting benzodiazepines can produce withdrawal symptoms within 1 to 2 days, whereas long-acting benzodiazepines take 5 to 10 days for withdrawal symptoms to occur following discontinuation. Manifestations include insomnia, agitation, anxiety, irritability, nausea, and diaphoresis. The other options list an antipsychotic (haloperidol) and antidepressants (fluoxetine and sertraline).
The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?
A. "I see."
B. "Really?"
C. "You're having difficulty sleeping?"
D. "Sometimes I have trouble sleeping too."
Correct answer: C
Rationale:
The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are nontherapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply.
A. Neglecting personal grooming
B. Looking at old photographs of family
C. Participating in a senior citizens program
D. Visiting the spouse's grave once a month
E. Decorating a wall with the spouse's pictures and awards received
Correct answers: B, C, D, E
Rationale:
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.
A victim of a sexual assault is being seen in the crisis center. The client states, "I still feel as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?
A. "You need to try to be realistic. The rape did not just occur."
B. "It will take some time to get over these feelings about your rape."
C. "Tell me more about the incident that causes you to feel as if the rape just occurred."
D. "What do you think that you can do to alleviate some of your fears about being raped again?"
Correct answer: C
Rationale:
The correct option allows the client to express ideas and feelings more fully and portrays an unhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem-solving totally on the client.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially?
A. Move the client next to the nurses' station.
B. Use an indirect light source and turn off the television.
C. Keep the television and a soft light on during the night.
D. Play soft music during the night, and maintain a well-lit room.
Correct answer: B
Rationale:
Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken by the nurse before leaving the room?
A. Instituting safety measures
B. Closing the curtains in the room
C. Lowering the volume on the television set
D. Giving the client the remote control for the television set
Correct answer: A
Rationale:
Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The nurse would institute safety measures before leaving the client's room to prevent injury as a result of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are useful but not essential to the client's safety in this situation.
On review of the client's record, the nurse notes that the admission to the mental health unit was voluntary. Based on this information, the nurse plans care, anticipating which client behavior?
A. Fearfulness regarding treatment measures
B. Anger and aggressiveness directed toward others
C. An understanding of the pathology and symptoms of the diagnosis
D. A willingness to participate in the planning of the care and treatment plan
Correct answer: D
Rationale:
In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands the illness, only the client's desire for help.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse?
A. "Why don't you tell your spouse about this?"
B. "What do you find difficult about this situation?"
C. "This is not the best time to make that decision."
D. "I agree with you. You should get out of this situation."
Correct answer: B
Rationale:
The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse would not agree with the client, and the nurse would not request that the client provide explanations.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior?
A. Normal behavior
B. Evidence of the client's disturbed body image
C. Regression as the client is moving toward the community
D. Indicative of the client's ambivalence about hospital discharge
Correct answer: B
Rationale:
Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?
A. Chess
B. Writing
C. Board games
D. Group exercise
Correct answer: B
Rationale:
Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them or are group activities and need to be avoided because they can stimulate aggression and increase psychomotor activity.
The parent of a child diagnosed with attention deficit hyperactivity disorder has been given instructions about how to administer methylphenidate. Which response by the parent shows an understanding of the information about the best way to administer the medication?
A. At bedtime
B. After breakfast
C. At the evening meal
D. With a bedtime snack
Correct answer: B
Rationale:
Children with attention deficit hyperactivity disorder would take the morning dose after breakfast and the last daily dose at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. The other options are incorrect.
The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action would the nurse plan to engage in during the working phase of the nurse–client relationship?
A. Exploring the client's ability to function
B. Exploring the client's potential for self-harm
C. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful
D. Inquiring about and examining the client's feelings for any that may block adaptive coping
Correct answer: D
Rationale:
The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.
A. "I'm afraid of spiders."
B. "I keep reliving the robbery."
C. "I see that face everywhere I go."
D. "I don't want anything to eat now."
E. "I might have died over a few dollars in my pocket."
F. "I have to wash my hands over and over again many times."
Correct answers: B, C, E
Rationale:
Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?
A. Requesting that a peer remain with the client at all times.
B. Removing the client's clothing and placing the client in a hospital gown.
C. Assigning to the client a staff member who will remain with the client at all times.
D. Admitting the client to a seclusion room where all potentially dangerous articles are removed.
Correct answer: C
Rationale:
Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown or requesting that a peer remain with the client would not ensure a safe environment. Seclusion would not be the initial intervention, and the least restrictive measure would be used.
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply.
A. Dental decay
B. Moist, oily skin
C. Loss of tooth enamel
D. Electrolyte imbalances
E. Body weight well below ideal range
Correct answers: A, C, D
Rationale:
Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.
A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result would the nurse review before administering the first dose of this medication?
A. Platelet count
B. Blood clotting tests
C. Liver function studies
D. Complete blood count
Correct answer: C
Rationale:
Risperidone is an atypical antipsychotic. A baseline assessment of renal and liver function needs to be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level. None of the other diagnostics are relevant to this medication.
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?
A. Milieu therapy
B. Interpersonal therapy
C. Behavior modification
D. Support group therapy
Correct answer: A
Rationale:
All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist–client relationship is often used as a way for clients to examine other relationships in their lives. Behavior modification is based on rewards and punishment. Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.
A. Initiate confinement measures.
B. Acknowledge the client's behavior.
C. Assist the client to an area that is quiet.
D. Maintain a safe distance from the client.
E. Allow the client to take control of the situation.
Correct answers: B, C, D
Rationale:
During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
A. A client with pneumonia
B. A client undergoing diagnostic tests
C. A client who thrives on managing others
D. A client who could benefit from the client's assistance at mealtime
Correct answer: B
Rationale:
The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?
A. Hypotension, ataxia, hunger
B. Stupor, lethargy, muscular rigidity
C. Hypotension, coarse hand tremors, lethargy
D. Hypertension, changes in level of consciousness, hallucinations
Correct answer: D
Rationale:
Symptoms associated with alcohol withdrawal delirium typically include hypertension, tachycardia, nausea and vomiting, tremors (especially in the hand), sweating, anxiety, agitation, tactile disturbances, hallucinations such as auditory or visual disturbances, headache, and disorientation.
When a client develops neuroleptic malignant syndrome, the nurse ensures that which medication is available on the unit to address this complication?
A. Phytonadione
B. Bromocriptine
C. Protamine sulfate
D. Enalapril maleate
Correct answer: B
Rationale:
Clients taking antipsychotic medications are at risk for neuroleptic malignant syndrome. Bromocriptine, an antiparkinsonian prolactin inhibitor, is used in the treatment of neuroleptic malignant syndrome. Other treatments for neuroleptic malignant syndrome include intravenous dantrolene and electroconvulsive therapy for more severe cases. Phytonadione is the antidote for warfarin overdose. Protamine sulfate is the antidote for heparin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor used to treat hypertension.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
A. Communicate expected behaviors to the client.
B. Ensure that the client knows that they are not in charge of the nursing unit.
C. Assist the client in identifying ways of setting limits on personal behaviors.
D. Follow through about the consequences of behavior in a nonpunitive manner.
E. Enforce rules by informing the client that they will not be allowed to attend therapy groups.
F. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
Correct answers: A, C, D, F
Rationale:
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that they are not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules by informing the client that they will not be allowed to attend therapy groups is a violation of a client's rights.
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?
A. Witnessing a murder
B. The death of a loved one
C. A fire that destroyed the client's home
D. A recent rape episode experienced by the client
Correct answer: B
Rationale:
A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis or disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).
The nurse is preparing a client with schizophrenia and a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
A. "My medications will help my anxious feelings."
B. "I'll go to support group and talk about what I am feeling."
C. "When I have command hallucinations, I'll call a friend for help."
D. "I need to get enough sleep and eat well to help prevent feeling anxious."
Correct answer: C
Rationale:
The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, would be contacted to discuss whether the client has intentions for self-harm or to hurt others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.
A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan would include which nursing intervention?
A. Obtain daily drug blood levels.
B. Provide the client a tyramine-free diet.
C. Assess the client for anticholinergic effects.\
D. Obtain postural blood pressure prior to each medication administration.
Correct answer: D
Rationale:
Amitriptyline hydrochloride is a tricyclic antidepressant. A common side/adverse effect is orthostatic blood pressure changes, which can produce hypotension and tachycardia. The tachycardia can be frightening to the client, and the hypotension is dangerous because it may result in dizziness and falling. The client must be instructed to move slowly from a lying to a sitting or standing position to avoid injury if these changes are experienced. The client may experience some side/adverse effects, such as sedation, dry mouth, constipation, and blurred vision (anticholinergic effects). However, these effects are transient and will diminish with time. A tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for the client taking lithium.