Delusions
A client states, “The nurse at the desk is laughing because she knows what I did last night.”
This statement is best classified as which type of delusion?
Delusions of Reference
A nurse notes that a client consistently interprets neutral comments as insults, is reluctant to share information, and frequently questions staff motives. Which personality disorder is most consistent with these behaviors?
Paranoid Personality Disorder
Which medication requires the nurse to monitor for hypertensive crisis when taken with foods high in tyramine?
Phenelzine
A nurse suspects child physical abuse. Which finding is most concerning?
A. Bruises on the shins of a toddler
B. Burns on the palms of both hands
C. A fractured clavicle from a fall
D. Scrapes on the knees of a preschooler
B. Burns on the palms of both hands
The provider prescribes digoxin 0.125 mg PO daily. The medication label reads 0.25 mg per tablet.
How many tablets should the nurse administer?
1/2 Tablet
A client with schizophrenia says, “There is a device implanted in my brain that controls my thoughts and movements.”
Which type of delusion is this?
Delusion of Control
A client tells the nurse, “You’re the only one who understands me. Everyone else here is terrible.” The client later states, “You’re just like the rest of them. I hate you.”
Which personality disorder is most consistent with this behavior?
Borderline Personality Disorder
A client receiving risperidone develops restlessness, pacing, and an inability to sit still. Which medication would the nurse anticipate being prescribed?
Propranolol
An older adult is admitted with dehydration, poor hygiene, and pressure injuries. The caregiver states, “They just refuse to eat or bathe.” Which type of abuse is most likely?
A. Physical abuse
B. Emotional abuse
C. Elder neglect
D. Financial exploitation
C. Elder Neglect
A child weighing 22 lb is prescribed ceftriaxone 50 mg/kg/day in two divided doses.
How many mg per dose should the nurse administer?
250mg per dose
The nurse notes that a client repeatedly insists, “My stomach is rotting inside me even though the doctors say nothing is wrong.”
Which delusion is the client experiencing?
Somatic Delusion
A client avoids social interactions, desires relationships but fears rejection, and reports feeling “socially inadequate.” Which personality disorder best fits this presentation?
Avoidant Personality Disorder
Which medication is most appropriate for treating acute manic agitation in a client with bipolar disorder?
Olanzapine
A nurse is caring for a client who reports intimate partner violence (IPV). Which nursing action is most appropriate?
A. Encourage the client to leave the relationship immediately
B. Report the abuse to law enforcement
C. Validate the client’s experience and assess safety
D. Ask what the client did to provoke the abuse
C. Validate the clients experience and assess safety
The provider orders 1,000 mL of 0.9% NS over 8 hours.
What rate should the nurse set on the IV pump?
125ml/hr
A client hospitalized for severe depression states, “I don’t exist anymore. My organs have stopped working and the world ended already.”
Which delusion is most consistent with this statement?
Nihilistic Delusion
A client exhibits eccentric dress, odd speech patterns, and believes they can read others’ thoughts. Which personality disorder is most consistent with these findings?
Schizotypical Personality Disorder
A nurse is reviewing medications for a client with schizophrenia and type 2 diabetes. Which antipsychotic requires the most caution?
Clozapine
Which situation requires mandatory reporting by the nurse?
A. Adult reporting sexual assault and refusing police involvement
B. Teen reporting emotional abuse by a parent
C. Elder client with unexplained bruises and malnutrition
D. Adult client reporting verbal abuse by a spouse
C. Elder client with unexplained bruises and malnutrition
An IV is ordered to infuse 500 mL over 4 hours using tubing with a drop factor of 15 gtt/mL.
What is the drip rate in gtt/min?
(Round to the nearest whole number.)
31 gtt/min
A client becomes angry when the nurse denies a request and responds, “You can’t talk to me like that. I’m the CEO of this hospital and I own this city.”
Which type of delusion is being demonstrated?
Grandiose Delusion
A nurse is caring for a client who frequently manipulates staff by telling different stories to different nurses to get what they want. Which personality disorder is most associated with this behavior?
Antisocial Personality Disorder
A client with schizophrenia receiving haloperidol develops sustained muscle contractions of the neck and jaw. Which medication should the nurse administer first?
Benztropine
A nurse suspects sexual abuse in a child. Which finding is most suggestive?
A. Regression to bedwetting
B. Fear of strangers
C. Knowledge of sexual acts beyond developmental level
D. Nightmares
C. Knowledge of sexual acts beyond developmental level
A vial contains 1 g of medication. After reconstitution with 10 mL of sterile water, the concentration is 100 mg/mL.
The provider orders 350 mg IV.
How many mL should the nurse administer?
3.5ml