Medication SE
A client with schizophrenia has been started on medication therapy with clozapine. The nurse would assess the results of which laboratory study to monitor for adverse effects from this medication?
1. Platelet count
2. Blood glucose level
3. Liver function studies
4. White blood cell count
4. White blood cell count
Which of the following factors is identified as a risk factor for developing addictions?
1. High school performance
2. Peer pressure
3. Higher socio-economic status
4. Independent nature
2. Peer pressure
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?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime
2. A client undergoing diagnostic tests
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continuing contact with a crisis counselor
4. Eliminating all anxiety from daily situations
2. Identifying anxiety-producing situations
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.
1.Tremors
2.Anorexia
3.Irritability
4.Nervousness
5.Hot, dry skin
6.Muscle cramps
1.Tremors
3.Irritability
4.Nervousness
A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?
1. Complaints of insomnia
2. Complaints of hunger and fatigue
3. A pulse rate of less than 60 beats per minute
4. Frequent handwashing with hot, soapy water
4. Frequent handwashing with hot, soapy water
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?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
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?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations
4. Hypertension, changes in level of consciousness, hallucinations
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?
1. “Why don’t you tell your spouse about this?”
2. “What do you find difficult about this situation?”
3. “This is not the best time to make that decision.”
4. “I agree with you. You should get out of this situation.”
2. “What do you find difficult about this situation?”
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
1. Psychosis
2. Repression
3. Conversion disorder
4. Dissociative disorder
3. Conversion disorder
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for its presence?
1. Dorsiflex the client’s foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward.
3. Ask the client to extend the arms.
The nurse notes that a client with schizophrenia who is receiving an antipsychotic medication is moving the mouth, protruding the tongue, and grimacing while watching television. The nurse determines that the client is experiencing which medication complication?
1. Parkinsonism
2. Tardive dyskinesia
3. Hypertensive crisis
4. Neuroleptic malignant syndrome
2. Tardive dyskinesia
A nurse is review a client's risk for substance use disorder. Which of the following information about ingestion routes accurately describes substance addiction potential?
1. Some routes of substance use give the addict slower, more drawn-out pleasure from the drug.
2. Taking pills orally increases the risk for addictions because pills are easy to access and use.
3. The route does not make a difference, but the specific drug consumed is the factor.
4. Smoking or injecting a substance increases the risk for addition.
4. Smoking or injecting a substance increases the risk for addition.
The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client’s room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
1. Allow the client to complete the exercise program.
2. Interrupt the client and weigh the client immediately.
3. Tell the client that exercising rigorously is not allowed.
4. Interrupt the client and offer to take the client for a walk.
4. Interrupt the client and offer to take the client for a walk.
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?
1. Witnessing a murder
2. The death of a loved one
3. A fire that destroyed the client’s home
4. A recent rape episode experienced by the client
2. The death of a loved one
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk independently.
6. The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.
1. The client is aphasic.
2. The client has weakness on the right side of the body.
4. The client has weakness on the right side of the face and tongue.
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level?
1. Toxic
2. Normal
3. Slightly above normal
4. Excessively below normal
1. Toxic
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide stimulation in the environment.
5. Provide reality orientation as appropriate.
6. Maintain NPO (nothing by mouth) status.
1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
5. Provide reality orientation as appropriate.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention?
1. Encouraging quiet reading and writing for the first few days
2. Identification of physical activities that will provide exercise
3. No socializing activities until the client asks to participate in milieu
4. A structured program of activities in which the client can participate
4. A structured program of activities in which the client can participate
A nurse is caring for a client who has Alzheimer's disease and requires assistance with bathing and getting dressed in the morning. The nurse should identify that the client is in which of the following stages of the disease?
1. Mild
2. Moderate
3. Severe
4. Terminal
2. Moderate
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? Select all that apply.
1.Place the client on a cardiac monitor.
2.Notify the primary health care provider (PHCP).
3.Put the client on NPO (nothing by mouth) status except for ice chips.
4.Review the client’s medications to determine whether any contain or retain potassium.
5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
1.Place the client on a cardiac monitor.
2.Notify the primary health care provider (PHCP).
4.Review the client’s medications to determine whether any contain or retain potassium.
A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse would instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply.
1. Figs
2. Yogurt
3. Crackers
4. Aged cheese
5. Tossed salad
6. Oatmeal raisin cookies
3. Crackers
5. Tossed salad
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.
1. Dental decay
2. Moist, oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range
1. Dental decay
3. Loss of tooth enamel
4. Electrolyte imbalances
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
1.Communicate expected behaviors to the client.
2.Ensure that the client knows that they are not in charge of the nursing unit.
3.Assist the client in identifying ways of setting limits on personal behaviors.
4.Follow through about the consequences of behavior in a nonpunitive manner.
5.Enforce rules by informing the client that they will not be allowed to attend therapy groups.
6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.
1.Communicate expected behaviors to the client.
3.Assist the client in identifying ways of setting limits on personal behaviors.
4.Follow through about the consequences of behavior in a nonpunitive manner.
6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.
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.
1. “I’m afraid of spiders.”
2. “I keep reliving the robbery.”
3. “I see that face everywhere I go.”
4. “I don’t want anything to eat now.”
5. “I might have died over a few dollars in my pocket.”
6. “I have to wash my hands over and over again many times.”
2. “I keep reliving the robbery.”
3. “I see that face everywhere I go.”
5. “I might have died over a few dollars in my pocket.”
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low-Fowler’s side-lying position
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously