Med Surg A, B & C, RN Adult Med Surg A, ATI MED SURG, ATI A, ATI B, ATI C (Answered fall 2022) Test Bank 500+ 2022.

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Med Surg A, B & C, RN Adult Med Surg A, ATI MED SURG, ATI A, ATI B, ATI C (Answered fall 2022) A A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the fol... lowing information should the nurse include in the teaching? A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? A nurse is admitting a client who has active TB. Which of the following types of transmission precautions should the nurse initiate? A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A nurse on a medsurg unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? A nurse is receiving report on a client who is postop following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group? A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5mL. how many mL should the nurse administer? A nurse is checking the ECG rhythm strip for a client who has temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? A nurse is providing discharge instructions to a client who has active TB. Which of the following information should the nurse include in the instructions? A nurse is providing preop teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? A nurse is assessing a client who is postop following a TURP and notes clots in the clients indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? A nurse is reviewing the lab results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? A nurse is caring for a client who is receiving TPN and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following acions should the nurse take? A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? A nurse is caring for a client who is 8 hr postop following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? A nurse is providing postop teaching for a client who had a total knee arthroplasty. Which if the following instruction should the nurse include? A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following lab values is a manifestation of osteomyelitis and should be reported to the provider? A nurse is caring for a client who has a positive culture for MRSA. Which of the following actions should the nurse take? A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bass. Which of the following acitons should the nurse anticipate taking? A nurse is assessing a client who is postop following a thyroidectomy. Which of the following findings is the nurses priority? A nurse is providing education to a client who has TB and their family. Which of the following information should the nurse include in the teaching? A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing AD? A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take A nurse is providing teaching to a client who has AIDS. Which of the following statement by the client indicates an understanding of the teaching? A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client meds is a contraindication for the surgery and notify the provider A PACU nurse is assessing a client who is postop following a right nephrectomy. The client's initial vital signs were heart rate 80/min, BP 130/70, RR 16/min, and temp 96.8. which of the following vital sign changes should alert the nurse that the client might be hemorrhaging A nurse is reviewing the lab results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates and understanding of the teaching? A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? A home health nurse is providing teaching to a client who has stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching A nurse is caring for a client who is receiving mechanical via a trah tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitors. Which of the following statements by the client reflects and understanding of the teaching? A nurse is caring for a client who is 4 hr postop following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? A nurse is reviewing the medical record of a client who is taking warfarin for chronic A. Fib. Which of the values should the nurse identify as a desired outcome for this therapy A nurse is providing discharge teaching to a client who is to self-administer heparin subcu. Which of the following statements by the client indicates an understanding of the teaching? A nurse is providing teaching to a client who has a severe form of stage II lyme disease. Which of the following statements made by the client reflects an understanding of the teaching A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? A nurse is planning care for a client who is postop following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? A nurse is evaluating the plan of care for 4 clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? A nurse is caring for a client following extubation of an ET tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (SATA) A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their catheter. Which of the following actions should nurse take to avoid restraining the client? A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include?(SATA) A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for a brachytherapy. Which of the following instructions should the nurse include? A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? A nurse is reviewing the lab findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a MI? 75. A nurse is performing a preop assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry."." Which of the following actions is the nurse's priority? A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of the condition? A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (SATA) - a nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant IBS. Which of the following instructions should the nurse include in the teaching? A nurse is providing discharge teaching to a client who is postop following a modified radical mastectomy. Which of the following instructions should the nurse include? - A nurse is administered packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? A nurse is teaching a client about the use of TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A nurse is caring for a client who has breast cancer and tells the nurse they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? - A nurse is caring for a client who has DKA. Which of the following should the nurse plan to administer? A nurse is reviewing the medical record of a client who has SLE. Which of the following findings should the nurse expect? A nurse is planning care for a client who is postop following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? A nurse is caring for a client who has terminal cancer. The client tells thenurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? a nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? A nurse is providing instructions to a client who has type 2 diabetes and a new prescription of metformin. Which of the following statements by the client indicates an understanding of the teaching? a nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding if the teaching? a nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? a nurse is caring for a client who has hypothyroidism. which of the following manifestations should the nurse expect? a charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA. which of the following statements by the new nurse indicates an understanding of the teaching? a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the following instructions should the nurse include in the teaching? a nurse is caring for a client who has a positive culture for c. diff. which of the following actions should the nurse take? a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is the priority assessment finding that the nurse should report to the provider? a nurse is planning care for a client who is scheduled for a throacentesis. which of the following interventions should the nurse include in the plan? a nurse is assessing a client who has had a suspected cerebrovascular accident. the nurse should place the priority on which of the following findings? a nurse is reviewing the ABG results of a client who has advanced COPD. which of the following results should the nurse expect? a nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation treatment. which of the following statements by the client indicates an understanding of the teaching? a nurse is assessing for compartment syndrome in a client who has a short leg cast. which of the following findings should the nurse identify as a manifestation of this condition? a nurse is providing teaching to a client who has a gastric ulcer a d a new prescription for omeprazole. the nurse should instruct the client that the medication provides relief by which of the following actions. a nurse is assessing a client who has peripheral arterial disease. which of the following findings should the nurse expect? a nurse is assessing a client following the completion of hemodialysis. which of the following findings is the nurse's priority to report to the provider? a nurse is reviewing the medical record of a client who has osteomyelitis and a prescription of gentamicin. which of the following findings from the client's medical record should indicate to the nurse the need to withhold the med? a nurse is reviewing the medical record of a client who has SLE. which of the following findings should the nurse expect? a nurse is providing teaching to a client who has a new prescription for psyllium. which of the following information should the nurse include in the teaching? a nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent her headaches. the nurse should identify that which of the following client meds interacts with feverfew? a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. which of the following statements should the nurse make? a nurse is caring for a client who is receiving TPN. a new bag is not available when the current infusion is nearly completed. which of the following actions should the nurse take? a nurse is providing discharge teaching to a client who has HF and a new prescription for a potassium-sparing diuretic. which of the following information should the nurse include in the teaching? a nurse is planning care for a client who is postop following a laparotomy and has a closed-suction drain. which of the following actions should the nurse take to manage the drain? a nurse in an emergency department is admitting a client who reports dyspnea and SOB. which of the following actions is the priority for the nurse to perform prior to administering oxygen? a nurse is obtaining a med history from a client who is scheduled to undergo cataract surgery. the nurse should recognize that which of the following client meds is a contraindication for the surgery and notify the provider? a nurse is caring for a client following extubation of her endotracheal tube 10 min ago. which of the following findings should the nurse report to the provider immediately a nurse is providing dietary teaching to a client who is postop following a thyroidectomy with removal of the parathyroid glands. the nurse should instruct the client to include which of the following foods to increase calcium in the diet? a nurse is preparing to assist with the insertion of a nontunneled percutaneous central venous catheter into a subclavian vein. the nurse should plan to place the client in which of the following positions? teaching to client with HTN and new med verapamil. what juice should client avoid? - client experiencing anaphylactic reaction, after patent airway, which is priority nursing intervention? client had nephrostomy tube inserted 12hrs ago. what should the nurse report to the provider? teaching to perimenopausal and has hormone replacement therapy. adverse effects to notify provider? older adult with cancer and a new prescription of opioid analgesic. which info should the nurse include in teaching? a nurse is providing med teaching to a group with seizure disorders. instruction about phenytoin? a nurse is caring for client with supraventricular tachycardia. which action should nurse take next? change of shift report with four clients. client with greatest risk of developing infection? - teach with self administration of heparin? client having seizure, nurse priority? female client with hx of UTI, nurse include in teaching ? cardiac assessment with MI 2 days ago. action after hearing this sound? client on bed rest and enoxaparin subcut, actions nurse take? postop following parathyroidectomy. priority action? pt with arterial line, following actions should nurse taking? teaching client about a fib and purpose of wearing a holter monitor. info should nurse include in the teaching? client with DKA, client condition improving? stroke on right hemisphere. nurse expect? client who has external fixation device for fracture. instruction for nurse plan of care? - receiving mechanical ventilation via trach tube. nurse recognizes complications with long term mechanical ventilation? teaching about asthma use of metered-dose inhaler. understand teaching? graves disease, picture with exophthalmos? leg cast and demonstration w/crutches on climbing stairs. identify steps older adult with fractured wrist following fall. last week i crashed my car bc my vision suddenly blurry. performing dressing change recovering from hemicolectomy. large part of bowel is protruding, action take first? older adult about osteoporosis prevention. meds increase risk for developing osteoporosis? client having modified radical mastectomy of right breast. intervention for plan of care? client with anemia and a prescription for an oral iron supplement. which of the following statements by teaching? program about prevention of atherosclerosis at health fair. recommendations plan to include? TPN 2000kcal per day. 500kcal/L; mL/hr client with chronic glomerulonephritis with oliguria. manifestation? reviewing lab results with aplastic anemia. potential complication? ED with full thickness burns over 20% of total body surface. administer first after patent airway and administer O2? client with UTI and prescription ciprofloxacin. instructions? teaching with AIDS. understanding of teaching? compound fracture 3 weeks ago, unexpected finding lab value of manifestation of osteomyelitis and report to provider? bilateral pneumonia, client is dyspneic with productive cough. action nurse take first? client who is hypokalemia. manifestations? client with suctioning the clients trach tube. indication for hypoxia? med hx who undergo allergy testing. nurse should discontinue which med before testing? client with type 1 DM and new prescription for insulin lispro. understands teaching? client postop total hip arthroplasty. lab value should nurse report? checking ECG rhythm strip for client has temp pacemaker. spike followed by QRS complex. Action take first? ED client reports vomiting and diarrhea past 3 days. findings client experience fluid volume deficit? PACU nurse client postop right nephrectomy. VS changes alert nurse client might be hemorrhaging? ED planning care for flail chest on right side in motor vehicle crash. action plan to take? providing discharge w patient with active TB, nurse teach? client who is 12hr postop following total hip arthroplasty. action nurse take? reviewing lab results w client has acute leukemia. expected finding? client has venous insufficiency about self-care. client understands teaching? client has end stage kidney disease about organ donation. nurse include in teaching? - client is exhibiting manifestations of a febrile reaction while receiving blood transfusion. meds should nurse administer? client receiving plasmapheresis through venous access site. action nurse take? client at client for a 1 week follow up visit after HF. nurse report to provider? preop teaching for client with scheduled for open cholecystectomy, action nurse take? acute care facility caring for client at risk for seizures. precautions nurse implement? client has bladder cancer and undergo cutaneous diversion procedure to establish ureterstomy. nurse include in teaching? assessing male client for inguinal hernia. which area should the nurse palpate to verify has inguinal hernia? client is 8hr postop total hip arthroplasty, client unable to void on bedpan. action nurse take first? B 1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. 4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia 6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones 7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. 8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia 9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. 10.A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic 11.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent 12.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed. 13.A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia 2 3 4 14.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. 15.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. 16.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding 17.A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache 18.A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale 19.A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch. 20.A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. 21.A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever 22.A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes 23.A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 24.A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower." 25.A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client's weights are hanging freely from the bed. 3) Check the client's bony prominences every 12 hr. 4) Cleanse the client's pin sites with povidone-iodine. 26.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication 27.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication 28.A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. 4) Keep draining lesions uncovered to air dry 29.A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric form. 30.A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." 3) "A piece of skin will be removed and grafted over the burned area." 4) "Large incisions will be made in the burned tissue to improve circulation." 31.A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception 2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain 32.A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler's position. 4) Moisten the client's lips with lemon-glycerin swabs. 33.A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face 4) Tremors 5) Obese extremities 2 3 34.A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily 35.A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." 36.A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures 37.A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." 38. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client's head of bed. 5) Apply a cervical collar to the client. 38.A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. 40.A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client's pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration. 41.A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin 42.A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. 4) Serve food at room temperature. 43.A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures 44.A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihistamine. 45.A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing. 46.A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 47.A nurse is assisting with planning care for a client who is recovering from a lefthemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function. 48.A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia 49.A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis 50.A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." 51.A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music 52.A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response 53.A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket 54.A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client's fluid intake. 3) Monitor the Homan's sign. 4) Maintain abduction of the right hip. 55.A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. 56.A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." 57.A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. 58.A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. 59.A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." 60.A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. 61.A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia 62.A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief 2 5 63.A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin 64.A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions 65.A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels. 66.A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn : 67.Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?" 68.A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk 69.A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy 70.A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye." 71.A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? 1) Increase in serum glucose 2) Increase in serum creatinine 3) Decrease in white blood cell count 4) Decrease in platelets 72. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position 4) Drop in systolic BP more than 10 mm Hg on inspiration 73.A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? 1) Attempt to determine what the client was looking for. 2) Explain the client's Alzheimer's diagnosis to the frightened client. 3) Reprimand the client for invading the other client's privacy. 4) Ask the client to apologize for his behavior. 74.A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? 1) Check pedal pulses every 15 min. 2) Perform passive range-of-motion for the affected extremity. 3) Remind the client not to turn from side to side. 4) Keep the client in high-Fowler's position for 6 hr. 75.A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? 1) Individuals at high risk should receive the live influenza vaccine. 2) Immunization for influenza should be repeated every 10 years. 3) The composition of the influenza vaccine changes yearly. 4) The influenza vaccine is necessary only for clients who have never had influenza. 76.A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? 1) Tell the client to have a family member call the provider to ask what options he plans to recommend. 2) Assure the client that the provider will tell him what is planned. 3) Help the client write down questions to ask his provider. 4) Provide the client with a pamphlet of information about cancer 77.A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? 1) "If you just sit quietly with your mother, I'm sure she will calm down." 2) "I'll talk with your mother and see if I can comfort her." 3) "It must be hard to see your mother so ill and upset." 4) "Your mother's crying seems to bother you more than it does her." 78.A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? 1) Temporary, reversible loss of brain function 2) Forgetfulness gradually progressing to disorientation 3) Sleeping more during the day than nighttime 4) Hyper vigilant behaviors 79.A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? 1) Limit fluid intake.. 2) Monitor client's cardinal fields of vision. 3) Encourage ambulation. 4) Ensure the room is brightly lit 80.A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? 1) Apply ice to the extremity 2) Monitor platelet levels 3) Restrict oral fluids 4) Administer vasodilating medications 81.A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? 1) Tuberculin skin test 2) Sputum culture for acid fast bacillus (AFB) 3) Bacille Calmette-Guérin (bCG) vaccine 4) Chest x-ray 82.A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL 83.A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? 1) "I took a laxative yesterday." 2) "I took my metformin before breakfast." 3) "I haven't had anything to eat or drink since last night." 4) "The last time I voided it was painful." 84.A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? 1) Expiratory wheeze 2) Pleural friction rub 3) Fine rales 4) Rhonchi 85.A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? 1) Remove the entire dressing at once. 2) Loosen the dressing by pulling the tape away from the wound. 3) Don clean gloves to remove the dressing. 4) Open sterile supplies before removing the dressing. 86.A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? 1) Prone with arms raised over the head. 2) Sitting, leaning forward over the bedside table. 3) High Fowler's position 4) Side-lying with knees drawn up to the chest. 87.A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? 1) Denial 2) Bargaining 3) Acceptance 4) Anger 88.A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler's position. 89.A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 1) Neck vein distention 2) Blood pressure 3) Body weight 4) Abdominal girth 90.A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1) Urticaria 2) Muscle pain 3) Hypotension 4) Distended neck veins 91.A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? 1) A continuous seizure state in which seizures occur in rapid succession 2) A sensory warning that a seizure is imminent 3) A period of sleepiness following the seizure during which arousal is difficult 4) A brief loss of consciousness accompanied by staring 92.A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 1) "The bright light in this room is really bothering me." 2) "My eye really itches, but I'm trying not to rub it." 3) "It's really hard to see with a patch on one eye." 4) "I need something for the horrible pain in my eye." 93.A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? 1) "You shouldn't feel any pain since the local area is anesthetized." 2) "Most clients report more discomfort from the preparation than from the procedure itself." 3) "You may feel some cramping during the procedure." 4) "Don't worry; you won't remember anything about the procedure due to the effects of the medication." 94.A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity 95.A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 1) Reducing anxiety 2) Increasing blood pressure 3) Increasing coughing 4) Increasing the client's respiratory rate 96.A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? 1) Frequent mood changes 2) Constipation 3) Sensitivity to cold 4) Weight gain 97.A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 1) Serosanguineous drainage 2) Mild erythema 3) Warmth 4) Fever 98.A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) 1) Polyuria 2) Blurry vision 3) Tachycardia 4) Polydipsia 5) Sweating 3 5 99.A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin 5) Symmetrical joint pain 2 3 4 100. A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 1) Respiratory difficulty 2) Confusion 3) Increased intracranial pressure 4) Joint pain 101.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacerbation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility. 102. A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary. 103.A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make adequate urine." 3) "I will need to take this medication for the rest of my life." 4) "This medication will boost my immune system." 104.A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling 105.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine. 106.A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I started." 4) "I will wear gloves when removing food from the freezer." 107.A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medication." 4) "I should take the medication with milk." 108.A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron 4) Folate 109.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb." 110.A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis 111.A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client's hip so that it is internally rotated. 4) Encourage foot exercises every 4 hr. 112.A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 1) Aphagia 2) Hoarseness 3) Tinnitus 4) Epistaxis 113.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function? 1) Antinuclear antibody 2) C-reactive protein 3) Erythrocyte sedimentation rate 4) Serum creatinine 115.A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision 116.A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client's head of bed. 3) Auscultate the client's abdomen. 4) Order a lunch tray for the client. 117.A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular appearance. 3) The wound has serosanguineous drainage. 4) The wound has a halo of erythema on the surrounding skin. 118.A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles 119.A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema 120.A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals. 2) Instruct the client to restrict food intake prior to treatment. 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy. 4) Encourage the client to drink a carbonated beverage 1 hr before meals. ???? 121.A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour 122.A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week." 4) "I will bend at the waist to tie my shoes." 123.A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea 124.A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? 1) Encourage the client to drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating. 125.A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction 126.A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite 127.A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes 128.A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? 1) Report of urinary retention 2) Elevated blood pressure above 140/90 3) Report of dryness with vaginal intercourse 4) Elevated body temperature above 37.8° C (100° F) 129.A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation 130.A nurse is caring for a client who has secondnd third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) ½ cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) ½ cup black beans with a brownie 4) Roast beef with romaine lettuce salad 131.A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? 1) Omit your daily dose of aspirin. 2) Take a laxative the evening before the procedure. 3) Expect to be drowsy for 24 hr following the procedure. 4) You will feel cold chills after the dye has been injected 132.A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? 1) "The pain is worse after I eat a meal high in fat." 2) "My pain is relieved by having a bowel movement." 3) "I feel so much better after eating." 4) "The pain radiates down to my lower back." 133.A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? 1) Promote the client's expression of feelings about loss of self-care ability. 2) Encourage the client to recall positive life events. 3) Schedule pain medication on a routine basis. 4) Suggest ways the client can continue interacting with social contacts. 134.A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? 1) "When my vision improves, I will be able to stop taking the eye drops." 2) "If I forget to take my eye drops, I should wait until the next time they are due." 3) "I should call the clinic before taking any over-the-counter medications." 4) "Every two years I will need to have my vision checked by an eye doctor." C 1. A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a. "You should continue this medication if you develop muscle rigidity". b. "You will experience weight loss while taking this medication." c. "You will notice your symptoms improve within 24 hours of taking this medication." d. "You should increase your consumption of complex carbohydrates." 2) A nurse is admitting a client who has generalized anxiety disorder. Which of the following actions should the nurse plan to take first? a. Provide the client with a quiet environment b. Determine how the client handles stress. c. Teach the client to use guided imagery. d. Ask the client to identify her strengths 3) A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following should the nurse report to the provider? a. States that he hasnt bathed in 2 days b. Reports eating twice in the past two weeks. c. Makes inappropriate sexual comments. d. Speaks in rhyming sentences. 4) A nurse is planning care for a client who has obsessive-compulsive disorder. Which of the following recommendation should the nurse include in the clients plan of care? a. Validation therapy b. Thought stopping c. Operant conditioning d. Reality orientation therapy 5) A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Encourage the client to join group activities b. Dim the lights in the clients room c. Provide detailed explanations to the client d. Administer methylphenidate 6. 6) A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first. a. Initiate referrals b. Review community resources c. Identify prior coping skills d. Discuss the importance of confidentiality 7. 7) A nurse overhears a client saying"I am a spy, a spy for the FBI .I am an I,an eye for an eye in the sky. Sky is up high." The nurse should document the clients statement as which of the following speech alterations? a. Echolalia b. Word salad c. Neologism d. Clang association 8) An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states "Im so worried that my mother is depressed" which of the following responses should the nurse make? a. Everyone gets depressed from time to time. b. You shouldnt worry about this because depressive disorder is easily treated. c. Older adults are usually diagnosed with depressive disorder as they age. d. Tell me the reasons you think your mother is depressed. 9. 9) A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan care? a. Meets own needs without manipulating others. b. Initiates social interactions with caregivers. c. Changes behavior as a result of peer pressure. d. Acknowledges his delusions are not real. 10) A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Snap a rubber band on your wrist when you think about checking the locks. b. Ask a family member to check the locks for you at night. c. Focus on abdominal breathing whenever you go to check the locks. d. Keep a journal of how often you check the locks each night. 11) A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicate the nurse is practicing the ethical principle of nonmaleficence? a. Provide the client with quality care regardless of their ability to pay for treatment. b. Educating the client about legal rights concerning treatment. c. Withholding the prescribed medication that is causing adverse effects for the client. d. Being truthful with the client about the manifestations of withdrawl. 12. 12) A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use? a. Crisis intervention to decrease anxiety. b. Aversion therapy to provide distraction c. Positive reinforcement to increase desired behavior. d. Systematic desensitization to extinguish the behavior. 13. 13) A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Ask the client to discuss precipitating events b. Speaks to the client in a high-pitched voice. c. Place the client in seclusion d. Have the client breathe into a paper bag. 14. 14) The nurse is caring for a client following a physical assault. The client states "I don't remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms? a. Repression b. Displacement c. Rationalization d. Denial 15. 15) A nurse is caring for a client who has anorexia nervosa. Which of the following findings require immediate intervention by the nurse? a. +2 edema of the lower extremities b. BUN 21 mg dL c. Lanugo covering the body d. Blood pH 7.60 16. 16) A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm herself and others. Which of the following is the priority intervention? a. Place the client in restraints b. Administer an anti-anxiety medication to the client c. Put the client in seclusion d. Set limits on the clients behavior 17) Dosage Calculation Question. osage calc 18) A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? a. Ask the clients family to encourage the client to receive ECT b. Inform the client that ECT does not require a consent. c. Document the clients refusal of the treatment in the medical record. d. Tell the client he cannot refuse the treatment because he was involuntarily committed. 19) A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first? a. Request a mental health consult for the client. b. Ask the client if she has thought about harming herself. c. Encourage the client to attend a grief support group. d. Discuss the clients coping skills. 20) A nurse is caring for a client who has borderline personality disorder and has been engaging in self- mutilation. The nurse should encourage the client to participate in which of the following groups. a. Dual diagnosis treatment group b. Dialectical treatment group c. Desensitization therapy d. Co-dependents support group. 21) The nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the Abnormal Involuntary Movement Scale to monitor for adverse effects of which of the following medications.? a. Amantadine b. Diphenhydramine c. Benztropine d. Haloperidol 22) A nurse is counseling a client following the death of a clients partner 8 months ago. Which of the following client statements indicates maladaptive grieving? a. I am so sorry for the times I was angry with my partner. b. I find myself thinking about my partner often. c. I still dont feel up to returning to work. d. I like looking at his personal items in the closet. 23. 23) A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan? a. The client will report a decrease in hallucinations. b. The client will communicate needs c. The client will verbalize improved mood d. The client will attend to personal hygiene. 24. 24) A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states "I cant stand to be touched by another person." Which of the following responses should the nurse make? a. Why don't you like to be touched by others b. Don't worry about it. Your anxiety will lessen once the massage begins. c. I will tell your provider you would like a treatment other than a massage. d. I will request that the massage therapist wear gloves during your treatment. 25. 25) A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Encourage physical activity for the client during the day b. Discourage the client from expressing feelings of anger c. Keep a bright light on in the clients room at night. d. Identify and schedule alternative group activities for the client. 26. 26) A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role as the monopolizer? a. The mother who expresses hostility toward her spouse. b. The adolescent son who refuses to share personal feelings. c. The father who intervenes whenever the siblings argue. d. The adolescent daughter who attempts to dominate the conversation. 27. 27) A nurse is developing a teaching plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include in the teaching plan? a. The client might have a headache after treatment. b. The client will experience seizure during treatment. c. The client will require intubation after treatment. d. The client is at risk for aspiration during treatment. 28. 28) A nurse is providing teaching about disulfiram to a client who has a history of alcohol use. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. "You will need to take the medication once daily" b. "you will receive treatment in an inpatient setting" c. "You should avoid using mouthwash that contains alcohol" d. "you should avoid drinking carbonated beverages while taking the medication" e. "you can expect to develop a physical dependence to the medication" c 29. 29) A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? a. Avoid power struggles by remaining neutral b. Allow the client to set limits for his behavior c. Provide in-depth explanation of nursing expectations d. Encourage the client to participate in group activities 30. 30) A nurse is assessing a young adult female client for schizophrenia. Which of the following findings should the nurse identify as a risk factor for this condition? a. Environmental stress b. Gender c. Depression d. Birth order 31. 31) A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching? a. The client exhibits an inflated sense of self b. The client develops an inability to concentrate c. The client increases participation in social activities d. The client begins sleeping more than usual 32. 32) A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium? a. The client is unable to recognize objects. b. The client manifestations developed suddenly c. The client has a flat affect d. The client's speech is slow and repetitious 33) A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make? a. " You know that's not true, because it is against the law for others to read your mail" b. "All of your letters come sealed, so that seems unlikely" c. "It must be frightened to think that someone is reading your mail" d. "why do you think the government wants to read your mail?" 34) A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the following clinical findings should the nurse expect? a. Heart rate 48 min b. Temperature 40 C (104 F) c. WBC 3,000 mm3 d. Hypotonicity 35) A nurse is reviewing the medical record of a client who is taking clozapine. For which of the following findings should the nurse withhold the medication and notify the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) a. WBC count b. Blood glucose level c. Report of photosensitivity d. Heart Rate 36) A nurse is caring for a client who has personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? a. Talking negatively about other staff members b. Expressing frustration regarding unit rules c. Reacting to the nurse as though she were his mother d. Refusing to participate in group activities 37) A nurse in a mental health facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting? a. A community meeting b. A medication group c. A self-help meeting d. A symptom-management group 38) A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Request that the client's guardian sign the consent b. Ask the charge nurse to obtain informed consent c. Contact the facility social worker to obtain the consent d. Explain implied consent to the client's family 39) A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? a. Hand tremors b. Rapid speech c. Fatigue d. Seizures 40) A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching? a. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD" b. "Talking about the traumatic experience is recommended" c. "Response prevention is an effective treatment for PTSD" d. "You should try to limit the number of hours that you sleep each day" 41) A nurse is assessing a client who has bipolar disorder and is taking lamtropine. Which of the following findings is the nurses priority? a. Thyroid-stimulating hormone (TSH) 4.0 microunits per mL b. Alanine transaminase (ALT) 20 IU per L c. Skin rash d. Epistaxis 42. 42) A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take? a. Manage the client's loud, rambling, and incoherent communication patterns b. Direct the client to perform her own daily hygiene and grooming tasks c. Assist the client to identify somatic and thought-broadcasting delusions d. Use medication to decrease frequency of auditory and visual hallucination. 43. 43) A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase? a. Inform the client about confidentiality rights b. Establish boundaries between the nurse and the client c. Set short and long-term objectives for the future d. Evaluate progress toward predetermined goals 44. 44) A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Occupational therapist d. Social worker 45. 45) A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanism is the client demonstrating? a. Denial b. Displacement c. Compensation d. Rationalization 46. 46) A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference? a. "The client is just like my brother who finally overcame his habit" b. "The client needs to accept responsibility for his substance use" c. "The client generally shares his feelings during group therapy session" d. "The client asked me to go on a date with him, but I refuse" 47. 47) A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first? a. Establish a rapport to foster trust b. Implement continuous one-to-one observation c. Ask the client to sign a no-suicide contract d. Encourage the client to participate in group therapy 48. 48) A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanism. Which of the following examples should the nurse include in the teaching? a. A student who is upset with her teacher writes a story about an excellent student b. A school-age child whose mother died 2 years ago talks about her in present tense. c. A woman who has health concern postpones a medical appointment until after a vacation. d. An adult who was sexually abused as a child is unable to remember the incident 49. 49) A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse's priority? a. High fever b. Urinary hesitancy c. Insomnia d. Headache 50. 50) A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse include in the care plan? a. The client recognizes the importance of others b. The client conforms to social norms regarding clothing choices c. The client reduces self-dramatization d. The client treats others with respect 51. 51) A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Negotiate with the client how much weight she should gain each week. b. Decrease the client's daily intake of fiber c. Weight the client weekly for the first month d. Notify the client about designated time for meals 52. 52) A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experience a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following? a. Therapist modeling b. Positive reinforcement c. Frequent practice d. Biofeedback 53. 53) A nurse in the emergency department is counseling a client who reports experiencing intimate partner violence. Which of the following actions should the nurse take? a. Request permission from the client to take photographs of the injuries b. Offer to help the client escape form the partner the next time violence occurs c. Determine what the client did to trigger the violent incident d. Tell the client that staying with the partner shows a lack of judgment 54. 54) A nurse is caring for a client who has prescription for phenelzine. The nurse should instruct the client to avoid which of the following over-the-counter medications? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. Docusate sodium 55. 55) A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take? a. Avoid asking direct questions about the client's experience b. Convey sympathy for the client's experience c. Tell her client her experience is not real d. Focus the client on reality-based activities 56. 56) A nurse is caring for a client who has just returned to the unit after receiving an electroconvulsive therapy treatment. Which of the following assessments is the nurse's priority? a. First voiding b. Short-term memory c. Presence of gag reflex d. Return of bowel sounds 57. 57) A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make? a. "I think you should ignore the comment" b. "You sound upset about today's session" c. "Why do you think that he said that to you?" d. "I agree that the comment was inappropriate" 58. 58) A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? a. Hypotension b. Insomnia c. Bradycardia d. Diminished reflexes 59. 59) A nurse is teaching a client who has bipolar disorder and a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching? a. "I should drink at least 6 liters of water per day" b. "I should be on a low-sodium diet" c. "I will call my doctor if I have diarrhea" d. "I will see my doctor to check my lithium levels annually" 60. 60) A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the following needs should the nurse collaborate with a clinical psychologist? a. The client needs a prescription for medication to promote nighttime sleep while in the facility b. The client needs to find a place to live after discharge c. The client needs to begin a group therapy program prior to discharge d. The client needs to relearn how to perform skill that require fine motor coordination 61. 61) A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000 per mm3 c. Urine pH 5.6 d. RBC 4.7 per mm3 62. 62) A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching? a. I will ensure the bedroom is dark while he is sleeping at night b. I will place a sliding bolt lock just above the doorknob c. I will notify law enforcement within 2 hours if he cannot be found d. I will give his most recent photo to the police 63. 63) A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following? a. Hypertensive crisis b. Cardiac toxicity c. Serotonin Syndrome d. Urinary retention 64. 64) A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? a. Potassium 3.8mEq per L b. Heart Rate 56 per min c. Temperature 35.6C (96.1F) d. Weight 10% below ideal weight 65. 65) A nurse us obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment finding in the client's history should the nurse report to the provider? a. Hepatitis B Infection b. Hypothyroidism c. Knee arthroplasty 1 month ago d. Recent head injury 66. 66) A nurse is providing crisis intervention for a client who was involved in a violent mass causality situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. help the client focus on a wide variety of topics regarding the crisis b. identify the client's usual coping style c. tell the client that his life will soon return to normal d. encourage the client to display anger toward the cause of the crisis 67. 67) A nurse in the community health facility is interviewing a client who recently lost his job. The client states "I was fired because my boss doesn't like me" Which of the following defense mechanisms is the client displaying? a. Rationalization b. Displacement c. Dissociation d. Repression 68) A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching? a. sit on the side of the bed for a few minutes before standing b. decrease the prescribed dose by half when mood improves c. avoid over the counter magnesium when taking this medication d. eat a snack before going to bed 69) A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan? a. give detailed instructions for completion of self-care activities b. confront the client when he exhibits inappropriate behavior c. provide finger foods to enhance caloric intake d. remove clocks from the client's room 70) A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care? a. discuss the appropriate use of assertive behavior with the client b. encourage the client to attend weekly support group meetings c. assist the client to maintain awareness of her thoughts and feelings d. implement measures to prevent intentional self-inflicted injury 1. A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first? a. Place the child in seclusion b. Use therapeutic hold technique c. Apply wrist restraints d. Administer risperidone 2. A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation? a. Chest x-ray b. ECG c. Coagulation studies d. Liver function test 3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders? a. Dependent b. Paranoid c. Borderline d. Histrionic 4. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take? a. Inform the client that he does not have the right to refuse medication b. Administer the medication to the client via IM injection c. Offer the client the medication at the next scheduled dose time d. Implement consequences until the client take the medication 5. A nurse is caring for a client in the emergency department who states she was beaten and sexually assault by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next? a. Conduct a pregnancy test b. Requests mental health consultation for the client c. Provide a trained advocate to stay with the client d. Offer prophylactic medication to prevent STI's 6. A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take? a. Request that the client's partner sign the consent form b. Cancel the scheduled ECT procedure c. Proceed with the preparation for ECT based on implied consent d. Inform the client about the risks of refusing the ECT 7. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? a. Rationalization b. Denial c. Compensation d. Displacement 8. A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client's depression. Which of the following statements by the nurse is appropriate? a. Please don't take what the client said seriously when she is depressed b. It's important that the client feel safe verbalizing how she is feeling c. Everybody feels that way about this client so don't worry about it d. I'll change your assignment to someone who doesn't have depressive disorder 9. A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse? a. The child is 10years old b. The child is homeschooled c. The has no siblings d. The child has cystic fibrosis 10. A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Keep a journal of how often you check the locks each night b. Snap a rubber band on your wrist when you think about checking the locks c. Ask a family member to check the lock for you at night d. Focus on abdominal breathing whenever you go to check the locks 11. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam a. Bradycardia b. Stupor c. Afebrile d. Hypertension 12. A nurse is creating a plan of care of a client who has anorexia nervosa. Which of the following intervention should the nurse include in the plan? a. Weigh the client twice per day b. Prepare the client for electroconvulsive therapy c. Set a weight gain goal of 2.2kg (5lbs) per week d. Encourage the client to participate in family therapy 13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following finding should the nurse expect? a. Readily initiates conversation b. Enjoys imaginative play c. Strong relationship with sibling and peers d. Attachment to objects that spin 14. A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention. a. Secure the client's valuable possessions b. Limit loud noises in the client's environment c. Encourage the client to participate in structured solitary activities d. Provide high calorie snacks to the client 15. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication. a. Blocks aldehyde dehydrogenase b. Prevents the anxiety of abstinence c. Reduces substance craving d. Decreases the likelihood of seizures 16. A nurse in an alcohol treatment facility is caring for a client who states "my job is so stressful that the only way I can come it is to drink." The nurse should recognize that the client is displaying which of the following defense mechanisms? a. Repression b. Rationalization c. Introjection d. Intellectualization 17. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills? a. How does this situation affect your life? b. Do you see your current situation affecting your future? c. Can you describe how you are currently feeling? d. How have you dealt with similar situations in the past 18. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following intervention is the nurse's priority at this time? a. Contact the adolescent's parents b. Suggest the adolescent join support groups c. Ask the adolescent if he is considering hurting himself d. Determine when the adolescent's change in behavior began 19. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Slurred speech b. Hypotension c. Bradycardia d. Hyperthermia 20. A nurse is assessing a client who has histrionic personality disorder. Which of the following finds should the nurse expect? a. Lack of remorse b. Attention seeking c. Splitting of staff d. Identity disturbance 21. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder? a. I will limit my mother's clothing choices when she is getting dressed b. I will provide my mother with detailed instructions about how to perform self-care c. I will wake my mother up a couple of times in the night to check on her d. I will discourage my mother from talking about physical complaints 22. A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect? a. Self-mutation b. Pacing back and forth c. Preoccupation with details d. Disorganized speech 23. a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa. Which of the following findings should the nurse expect? a. Blood glucose 100 mg dL b. T4 11 mcg dL c. Potassium 3.7 mEq L d. Hgb 10 g dL 24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching? a. This medication is given to help with extrapyramidal side effects b. This medication is given to help with your depression c. Benztropine helps alleviate your hallucinations d. Benztropine is used to counteract your tachycardia 25. A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan? a. Reinforce the clients orientation with the calendar b. Refute the clients perception of visual hallucinations c. Teach the client assertive techniques d. Assigned the client to a different caregiver each shift 26. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Discouraged client from expressing feelings of anger b. Identify and schedule alternative group activities for the client c. Encourage physical activity for the client during the day d. Keep a bright light on in the clients room at night 27. A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take? a. Encourage the client to suppress feelings of trauma b. Assign the same staff to care for the client each day c. Address the client in an authoritative manner d. Limit the amount of time spent with the client 28. A nurse is providing teaching for school age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching? a. I will provide a low sodium diet for my son b. I will make sure my son takes the last dose of the day by 4 PM c. I should expect my son to develop hand tremors d. I should contact my doctor if my son urinates excessively 29. A nurse is caring for a client who has a lithium level of 0.8 mEq L. Which of the following actions should the nurse take? a. Withhold the next does of lithium b. Repeat the lithium level test c. Administer the next does of lithium d. Recommended a low sodium diet 30. A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements. a. I want to learn how to change the way I react to problems within my family b. I want to understand why my past experiences are affecting my family relationships c. I want to improve my family's understanding of each other's boundaries d. I want each of my family members to be more aware of each other's feelings 31. A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wonders at night and has a history of previous falls. Which of the fund instructions should nurse including? (select all) in the teaching a. position the mattress on the floor b. Install sensor devices on outside doors c. Encourage physical activity prior to bedtime d. put locks at top of doors e. place the client in a reclining chair b d 32. A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity? a. Calcium 9.0 mg dL b. sodium 130 mEq L c. chloride 98 mEq L d. potassium 5.0 mEq L 33. A nurse is assisting with obtaining informed consent from client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Contact the facility social worker to obtain the consent b. Explain implied consent to the clients family c. Request that the clients Guardian signed the consent d. Ask the charge nurse to obtain an informed consent 34. A nurse is giving a presentation about intimate partner abuse for community group. Which of the following statements buy a group member indicates understanding of teaching? a. Survivors of abuse often feel guilty b. abusers often have high self-esteem c. the honeymoon stage of violence usually gets longer over time d. as abuse continues, victims become more determined to be independent 35. A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority? a. The client joins a support group b. the client identifies techniques to reduce her stress c. The client develops a safety plan d. The client identify support systems 36. A nurse is developing a behavioral contract with the client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract? a. Use projection during group therapy b. increase self-esteem c. use bargaining skills for behavioral consequences d. Decrease the number of verbal outbursts 37. A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider? a. Nausea b. Random blood glucose 130 mg dL c. Heart rate 104 per minute d. sore throat 38. A nurse is counseling and adult client whose parent just died. The client states, "My son is 4, and I don't know how he'll react when he finds out that grandpa died." The nurse should inform the client that the preschool age child commonly has which of the following concepts of death? a. Death is not permanent and the loved one may come back to life b. Death is contagious and can cause other people he loves to die c. Death creates an interest in the physical aspects of dying d. Death is a part of life that eventually happens to everyone 39. A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identified as a risk factor for violent behavior? a. Schizoid personality disorder b. Alcohol intoxication c. Dysthymic disorder d. long-term isolation 40. A nurse in a provider's office is assessing a school age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first? a. Request that the parent leaves the room while you interview the child b. Report suspected abuse to child protective services c. Ask the child how the injury occurred d. Determine the immediate safety needs of the child 41. An older adult client is brought to the mental clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, I'm so worried that my mother is depressed. Which of the following responses should the nurse make? a. Older adults are usually diagnosed with depressive disorder as they age b. everyone gets depressed from time to time c. you shouldn't worry about this, because depressive disorder is easily treated d. tell me the reasons you think your mother is depressed 42. A nurse in a mental health facility is caring for a client. Which of the following actions the nurse take during though working phase of the nurse-client relationship? a. Summarize goals and objectives b. Address confidentiality c. promote problem-solving skills d. establish a participation contract 43. a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head and says, "please forgive me, I'm not sure what came over me I don't know why said those things." The nurse interprets this behavior as which of the following? a. Emotional lability b. Confabulation c. flight of ideas d. Neologism 44. A nurse is providing teaching for the family of a client who has dementia. Which of the following should the nurse include in the teaching as a contributing factor for this disorder? a. Hypotension b. alcohol use disorder c. Dehydration d. change in environment 45. A nurse is caring for a client who has been taking valproic acid. Which of the following is expected outcome of the medication? a. The client reports improved short-term memory b. the client has a decreased euphoric mood c. the client reports absence of auditory hallucinations d. the client has decreased anxiety 46. A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the phone information should the nurse include? a. This therapy works as a cure for major depressive disorders b. You will be awake and alert during the procedure c. You might experience confusion for a few hours after treatment d. This therapy will stimulate the vagus nerve to improve your mood 47. A nurse emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take? (Exhibit question) a. ask the client if she has eaten foods containing thyramine b. Give regular insulin subcutaneously to the client c. Prepare the client for electroconvulsive therapy d. administer dantrolene IV bolus to the client 48. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000 mm3 c. urine pH 5.6 d. RBC 4.7/mm3 49. A nurse is caring for a client who has schizophrenia and started taking clozapine two months ago. Which of the following laboratory results should the nurse report to the provider? a. WBC 3,000 mm3 b. Potassium 4.2 mEq L c. Hgb 16 g dL d. Platelets 300,000 mm3 50. A nurse is assessing the boundaries of a client's family one of the family members says to the client, " I know exactly what you're thinking right now." The nurse should recognize that the following family boundaries? a. Rigid b. Inconsistent c. Enmeshed d. Clear 51. A nurse is assessing a client who requires bupropion for smoking cessation. Which of the following findings in the client's history should the nurse recognized as a contraindication for taking this medication? a. Seizures b. Anemia c. Migraines d. Asthma 52. A nurse is caring for a client with Alzheimer's disease. Which of the following actions should the nurse take? a. Seat the client at a dining table with six or more residents b. provide the client with several choices for meal selection c. give complete directions before starting client care d. use symbols to assist the client in locating rooms 53. A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication? a. Anhedonia b. Waxy flexibility c. contractions of the jaw d. incongruent affect 54. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse's priority? a. High fever b. Insomnia c. Urinary hesitancy d. Headache 55. A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection? a. "I would like to sit with you for a while" b. "You feel upset when this happens?" c. "Let's work together to try to solve your problem" d. "Can you tell me what is happening now?" 56. A nurse is leading grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression? a. "I don't know how I could cope if I didn't have my family's support" b. "It'll be a long time before I'm happy again" c. "I don't feel anything but numbness anymore" d. "I feel like I'm angry at the whole world right now" 57. A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg 5 mL. How many mL should the nurse administer? (Round to nearest tenth) 2.5 58. A nurse is teaching the parent of a school age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching? a. Expect the child to gain weight while taking this medication b. Crush the medication and mix it with 120 mL (4 oz) of juice c. Therapeutic effects will occur within 24 hr of starting treatment d. Administer the medication before the child goes to school in the morning 59. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Place the client in a group therapy session b. Rotate staff members who work with the client c. Encourage the client to participate in physical activities d. Distract the client with increased environmental stimuli 60. A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide? a. The client is married b. The client is female c. The client is 50 years of age d. The client has diabetes mellitus 61. A nurse is performing a mental status examination for a client who has schizophrenia. The nurse should recognize that which of the following actions requires the client to think abstractly? a. Explain what to do if he misses the bus b. Determine the meaning of a proverb c. Name the last three presidents of the United States of America d. Count by adding sevens consecutively 62. A nurse is developing a plan of care for a school age child who has ADHD. Which of the following interventions should the nurse include in the plan? a. Administer olanzapine b. Institute consequences for deliberate behaviors c. Provide a stimulating environment d. Encourage thought stopping techniques 63. A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Social worker d. Occupational therapist 64. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Encourage the client to display anger toward the cause of the crisis b. Tell the client that his life will soon return to normal c. Identify the client's usual coping style d. Help the client focus on a wide variety of topics regarding the crisis 65. A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase? a. Manage conflict within the group b. Establish rapport with group members c. Encourage the use of problem-solving skills d. Maintain the group's focus on identified issues 66. A nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the following findings indicates the client is at an increased risk for suicide? a. Increased energy b. Hypersomnia c. Unkempt appearance d. Psychomotor retardation or c 67. A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To which of the following members of the client's interprofessional team should the nurse refer the client in order to help him relearn how to use eating utensils? a. Neuropsychiatrist b. Occupational therapist c. Physical therapist d. Social worker 68. A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse mandated to reportto the appropriate agency? a. A client who reports that she took $20 from the cash register where she works b. A client who reports that her partner ties their child to a bed as punishment c. A client who reports that he enjoys smoking marijuana on weekends d. A client who reports lying to his provider about having suicidal ideation 69. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider? a. Recent head injury b. Hepatitis B infection c. Hypothyroidism d. Knee arthroplasty 1 month ago 70. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms? a. Suppression b. Reaction formation c. Identification d. Compensation A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognizethat which of the following client medications is contraindicated when taken with selegiline? a. Wafarin b. Fluoxetine c. Calcium carbonate d. Acetaminophen A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client? a. Outside doors have locks b. The bed is in the low position c. Hallways are long distances d. The room has an area rug A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. "Ask a family member to check the locks for you at night" b. "Keep a journal of how often you check the locks each night" c. "Snap a rubber band on your wrist when you think about checking the locks" d. "Focus on abdominal breathing whenever you go to check the locks" A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse's priority? a. Insomnia b. Urinary hesitancy c. Headache d. High fever A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect? a. Failure to recognize familiar objects b. Altered level of consciousness c. Excessive motor activity d. Rapid mood swings A nurse in a mental health facility is interviewing a new client. Which of the following outcomes must occur if the nurse is to establish a therapeutic nurse-client relationship? a. The nurse is seen as an authority figure b. A written contract is established to clarify the steps of the treatment plan c. The nurse maintains confidentiality unless the client's safety is compromised d. The nurse is seen as a friend A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching? a. "If I cut myself, I can clean the wound with isopropyl alcohol" b. "I can wear my cologne on special occasions" c. "When I bake my favorite cookies, I can use pure vanilla extract for flavoring" d. "I can continue to eat aged cheese and chocolate" A nurse is planning care for a client who has narcissistic personality disorder. Which of the following actions is appropriate for the nurse to include in the plan of care? a. Ask the client to sign a no-suicide contract b. Remain neutral when communicating with the client c. Request an antipsychotic medication from the provider d. Provide the client with high-calorie finger foods A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm C. Urine pH 5.6 d. RBC 4.7/mm A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching? a. "I should avoid being around others if I think I'm having a relapse" b. "I should let my counselor know if I am having trouble sleeping" с. "I shouldn't worry about the voices because they are a part of my illness" d. "I should increase my carbohydrate intake to maintain my energy level" A nurse is assessing a client for negative manifestations of schizophrenia. Which of the following findings should the nurse expect? a. Echopraxia b. Delusions c. Anergia d. Tangentiality A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? a. Poor problem-solving skills b. Markedly neglected hygiene с. Significant weight loss d. Psychomotor retardation A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has ADHD. Available is methylphenidate 10mg/5ml liquid. How many ml should the nurse administer? (Round to nearest tenth) 2.5 A nurse is caring for a school age child who has a fractured arm. The child has other injuries that cause the nurse to suspect abuse. Which of the following actions is appropriate for the nurse to take when assessing the child's situation? a. Ask the parents directly if the child's fracture is due to physical abuse b. Direct the parents to the waiting room before interviewing the child c. Interview the child with the provider and social worker present d. Ask clarifying questions as the child explains how the injuries occurred A nurse is assisting with obtaining consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Ask the charge nurse to obtain informed consent b. Contact the facility social worker to obtain consent c. Request that the client's guardian sign the consent d. Explain implied consent to the clients family A nurse in a mental health facility is reviewing a client's medical record. Which of the following actions should the nurse take first? (Click on the exhibit button for additional information about the client. There are 3 tabs that contain separate categories of data) a. Teach the client about nutritional needs b. Initiate 0.9% sodium chloride with 40 mEq potassium chloride c. Administer acetaminophen 500 mg PO d. Encourage the client to attend group therapy sessions A nurse is assessing a client who has delirium. Which of the following findings require immediate intervention by the nurse? a. Rapid mood swings b. Command hallucinations c impaired memory d. Inappropriate speech patterns A nurse is developing a teach plan for family have an older adult client who's receive transcranial magnetic stimulation. Which of the following information to the nurse include in the teaching plan? a. The client is at risk for aspiration during treatment b. The client will experience a seizure during treatment c. The client require intubation after treatment d. The client might have a headache after treatment A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which fo the following assessment findings in the client's history should the nurse report to the provider? a. recent head injury b. hypothyroidism c. knee arthroplasty 1 month ago d. hepatitis B infection A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan? a. Provide written information about the clients treatment plan b. Monitor the client for splitting behaviors c. Encourage countertransferance when developing the nurse client relationship d. Isolate the client from social or group interactions A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take? a. ask the client about a recent change in laundry detergent b. Explain that the medication causes a temporary rash c. Apply hydrocortisone cream on the clients rash d. Withhold the next dose of the medication A nurse is caring for a client who begins yelling and pacing around the room which of the following actions should the nurse take? (SATA) a. Stand directly in front of the client b. Identify the clients stressors c. Request that security guards restrain the client d. Use a reward system for appropriate behavior , d A nurse is developing a plan of care for school-age child who has autism spectrum disorder. Which of the following intervention should the nurse include in the plan? a. Allow flexibility in the child's daily schedule b. Assign the child to a room with another child of the same age c. Discourage the child for making eye contact with caregivers d. Use a reward system for appropriate behavior The nurse is caring for a client who has posttraumatic stress disorder. Which of the following clinical findings associated associated with this disorder? a. Depersonalization b. Pressured speech c. Hyper vigilance d. Compulsive behavior A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the clients indicates an understanding of the teaching? a. "I will focus on mental image while concentration on my breathing" b. "I will practice replacing negative thoughts with positive self-statements" c. "I will progressively relax each of my muscle groups when feeling stressed" d. "I will learn how to voluntarily control my blood pressure and heart rate" A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine for five years. Which of the following assessments should the nurse use to determine if the client is experiencing adverse effects of the medication? a. Addictions severity index (ASI) b. Mood disorder questionnaire (MDQ) c. Abnormal involuntary movement scale (AIMS) d. Hamilton depression scale A nurse in a mental health facility is assessing a client for suicide risk factors using the the SAD PERSONS scale. Which of the following indicates a risk suicide? a. The client is married b. The client has diabetes mellitus c. The client is 50 years of age d. The client is female A nurse is providing crisis intervention for a client who is involved in violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with a client? a. Identify the clients usual coping style b. Help the client focus on a wide variety of topics regarding crisis c. Tell the client that his life will soon return to normal d. Encourage the client to display anger towards the cause of the crisis A nurse is caring for a client who is schizophrenia experiencing experiencing auditory hallucinations. Which of the following actions should the nurse take first? a. Encourage the client to listen to music b. Monitor the client for indications of anxiety c. Ask the client what she is missing d. Focus the client on reality-based topics A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication? a. A family member of the client b. Another client who speaks the same language as the client c. A translator of the same gender as the client d. A unit secretary who speaks the same language as the client A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect? a. Lethargy b. Hypothermia c. Hypertension d. Bradycardia A nurse is caring for a client who has severe depression and is scheduled to receive electro convulsive therapy. The nurse should recognize of the client will receive succinylcholine to prevent which of the following adverse effects? a. Muscle distress b. Aspiration c. Elevated blood pressure d. Decreased A nurse and an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following indicates a need for hospitalization. a. Temp 35.6 C (96.1) b. HR 56/min c. Weight 10% below ideal weight d. Potassium 3.8 mEq/L A nurse is caring for a client who is under observation for suicidal ideation's and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statement should the nurse make? a. "since you were trying to follow the treatment plan, we can submit your request to the provider" b. "we are concerned about you I need to keep you safe" c. "until your medication has reached therapeutic levels, you will need constant observation" d. "if you complete a contract that states you will not harm her self, you can be alone" A nurse on a mental health unit is leading a therapy session for a group of clients. One client challenge is a nurse and she has no empathy for others in the group. Which of the following actions should the nurse take? a. Request the the client leave the therapy session immediately b. Place the client in seclusion c. Reassign the client to another group d. Ask the client privately what is causing the anger A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. Inability to maintain employment b. Intense efforts to avoid abandonment c. Avoidance of interpersonal relationships d. Reluctance to discard worthless objects A nurse in a long-term care facility is assessing an older adult for depression. Which of the following findings should the nurse expect? a. Rapid mood swings b. sun downing c. insomnia d. rambling speech A nurse is assessing a client has been taking thioridazine for 2 weeks. The client reports and inability to be still. Which of the following adverse effects should the nurse suspect? a. Tardive dyskinesia b. Pseudo parkinsonism c. Akathisia d. Acute dystonia A nurse and a mental health facility is making plans for a clients discharge. Which of the following interdisciplinary team member should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Social worker c. Occupational therapist d. Recreational therapist A nurse an interviewing and client who was recently sexually assaulted. The client cannot recall the attack. The nurse should identify that the client is using which of the following defense mechanisms? a. Sublimation b. Reaction formation c. Suppression d. Rpression A nurse is assessing a client who has antisocial personality disorder. Which of the following client behaviors should the nurse expect? a. Attention seeking b. Anxious c. Projects blame d. Manipulative A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs? a. The client states that he will harm himself unless their strengths removed b. The client refuses to take his medication unless he is released c. The client demonstrates that he is oriented to place, person, and time d. The client is able to follow commands A nurse caring for a client who states, "Things will never work out." Which of the following responses to the nurse to make? a. "why do you feel like things will never work?" b. "have you been thinking about harming yourself?" c. "you should try to focus on yourself for a change" d. "maybe an antidepressant will make you feel better" A nurse and emergency department is caring for a client who reports recent sexual assault by her partner. Which of the following statements is the priority for the nurse to make? a. I want you to know that you are in a safe place here b. I can contact to support person for c. A trained sexual assault nurse will be assigned to your care d. I can provide information about an advocacy group in the area After assessing a client in a crisis situation, a nurse demonstrates the client is safe. Which of the following actions should the nurse take first? a. Help the client identify social support b. Involve the client in planning interventions c. Assist the client to lower his anxiety level d. Teach the client specific coping skills to handle stressful situations A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect? a. Acrocyanosis b. Amenorrhea c. Lanugo d. Hyponatremi A nurse is caring for a client who reports smoking marijuana several times per day. The client tells the nurse, "I don't know what the big deal is marijuana is a harmless herb". The nurse should identify that the client is displaying which of the following mechanisms? a. Rationalization b reaction formation c. Compensation d. Suppression A nurse is creating a plan of care for a client who is major depressive disorder. Which of the following intervention should the nurse include in the plan? a. Identify and schedule alternative group activities for the client b. Encourage physical activity for the client during the day c. Discourage the client from expressing feelings of anger d. Keep a bright light on in the clients room at night A nurse is teaching the family of a client who has Alzheimer's disease about the safety interventions for nighttime wondering, which of the following intervention should the nurse include? a. Place rubber back to throw rugs on tile floors b. Encourage the client to take naps during the day c. Install locks for the bottom of exits d. Place the clients mattress on the floor A nurse and a mental health facility is reviewing the lab results of a client who is taking lithium carbonate. which of the following findings places the client a risk for lithium toxicity? a. Calcium 10.0 b. WBC 6,0000 c. Sodium 132 mEq/L d. Aspartame aminotransferease 40 units/L A nurse in acute care facility is planning care for a client who has history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client? a. Monitor for orthostatic hypotension b. Administer methadone hydrochloride c. Implement seizure precautions d. Acidify the clients urine A nurse is developing a safety plan for a client who's experience intimate partner abuse. Which of the following items should the nurse include in the plan that will provide immediate safety for the client and her children? a. The phone numbers for law enforcement agencies b. A code phrase to use when it is time to leave the house c. The phone number of the local shelter d. A referral to a support group A nurse is caring for a client reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? a. Denial b. Rationalization c. Displacement d. Compensation A nurse is observing a newly licensed nurse administer and IM medication to a client who is manic and refused the medication. Which of the following actions should the nurse take first? a. Stop the newly licensed nurse from administering medication b. Call the provider for an alternate medication room c. Report the occurrence to the nurse manager d. Talk to the newly licensed nurse about the incident A nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner six months ago. Which of the following actions should the nurse take? a explain that it can take a year or more to learn to live with loss b. Discourage the client from reliving the events surrounding her loss c. Suggest that the client avoid social interactions that remind her of her partner d. Direct the client to maintain an unstructured daily routine A nurse is caring for a client who has bipolar disorder the client is walking in and out of rooms, speaking appropriately, and giggling. Which of the following actions should the nurse take? a. Tell the client there will be negative consequences for her behavior b. Take the clients for the day room to watch a movie with other clients c. Have the client return to her room to read a book d. Lead the client outside for a walk A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of aggression. Which of the following actions should the nurse include in the clients initial plan of care? a. Agree with the client when he's upset until he can calm down b. Provide physical exercise activity for the client c. Avoid eye contact with the client for the first few d. Ignore the clients hallucinations A nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the following findings should the nurse expect? a. Disorganized speech b. Height concentration c. Hypersomnia d. Agoraphobia A nurse is caring for a client who has schizophrenia. The clients employer calls to discuss the clients condition. Which of the following is the appropriate nursing act? a. Consult the client b. Consult the clients family c. Consult the provider d. Contact the facility legal department A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates accurate understanding of this medications affects? a. I know that I will be able to think more clearly now b. This medication will help me relax and feel less anxious c. I'll take my medicine at bedtime because it will make me drowsy d. I need to tell my doctor if I start gaining weight An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems very on interested in routine activities. The daughter states, "I'm so worried that my mother is depressed". Which of the following responses should the nurse take? a. "you shouldn't worry about this, because depressive disorder is easily treated" b. Older daughter usually diagnosed with depressive disorder as they age c. Tell me the reason you think your mother is depressed d. Everyone gets depressed from time to time A nurse is providing teaching to a client who has a new prescription for tranylcypromanine. Which of the following over-the-counter medications should the nurse instruct the client to avoid taking due to adverse interactions? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. Magnesium hydroxide A nurse in the emergency department is admitting a client who has a history of alcohol use disorder. The client has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a prescription for which of the following medications? a. Disulfiram b. Cholridiazepoxide c. Naltrexone d. Acamprosate A nurse is building a therapeutic relationship with a client who has an eating disorder. Which of the following activities should the nurse initiate during the relationships orientation phase? a. Mutually deciding and agreeing on the goals of the relationship b. Using memories to validate the relationship experience c. Discussing the incorporation of new strategies into daily life d. Teaching and encouraging the use of problem-solving skills A nurse is assessing a client who has schizophrenia. The client tells the nurse, "my heart exploded and my blood is draining out." The nurse should interpret the statement as which of the following manifestations? a. concrete thinking b. A visual hallucination c a somatic delusion d. Paranoia A nurse is interviewing a client who has schizophrenia. The client states, "aliens are going to abduct me at midnight tonight". Which of the following responses should the nurse make? a. Why are the aliens going to abduct you? b. You were safe from aliens here c. Believing that aliens will abduct you must be scary d. Have you ever been abducted by aliens before? A nurse is caring for a client who has generalized anxiety disorder and a history of substance abuse use disorder. Which of the following medications with the nurse expect the writer to prescribe? a. Chlordiazepoxide b. Clonazepam c. Busprione d. Alprazolam A nurse and an emergency department is creating a plan of care for a client who reports experiencing intimate partner violence. Which of the following interventions should the nurse include as a priority? a. teach the client stress reduction techniques b. Help the client devise a safety plan c. Refer the client to a support group d. Follow the facilities protocol for reporting the abuse A nurse in a mental health facility is caring for a client who is being aggressive towards other clients. Which of the following actions is the priority for the nurse to take? a. Assist the client to explore techniques to reduce stress b. Ask the client if he intends to harm others c. Role model healthy ways to express anger d. Suggest the client make a list of things to make him angry A nurse in the emergency department is caring for a client who has serotonin syndrome. The nurse should assess the client for which of the following manifestations? a. Hyperpyrexia b. Priapism c. Parathesisa d. Bradycardia [Show More]

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