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A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurses suspicion of delirium?

A) Slow Onset
B) Aphasia
C) Confabulation
D) Easily Distracted

D) Easily Distracted

*Extreme distractibility is a hallmark manifestation of delirium

A nurse is caring for a client who has anorexia nervosa. Which of the following criteria require hospitalization?

A) Weight loss 10% of total body weight in 3 months
B) Temp 96.1 F
C) Heart Rate 54 bpm

B) Temp 96.1 F

*Severe hypothermia, temp. lower than 96.8 due to loss of subcutaneous tissue or dehydration

HR < 40 bpm req. hospitalization

A nurse in a mental health clinic is caring for a client with bipolar disorder and reports that she stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

A) Photophobia
B) Hand tremors
C) Constipation

B) Hand tremors

-Can interfere with the clients ADL’s causing the client to stop taking the medication

A nurse is caring for a client with antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?

A) Control angry outbursts
B) No longer exhibits a fear of social situations
C) Refrains from manipulating others to earn dining-room privileges

C) Refrains from manipulating others to earn dining-room privileges
A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

A) A family with three generations in the same household
B) Older children who are responsible for their younger siblings
C) An adolescent who questions parental authority.

B) Older children who are responsible for their younger siblings

*There are no distinctions between the roles of family members

A nurse is caring for a client with schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2mg IM?

A) Shuffling gait
B) Hypotension
C) Blurred vision

A) Shuffling gait

*Benztropine is used to treat Parkinsonism manifestations-such as shuffling gait

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client’s turn, she does not respond. Which action should the nurse take?

A) Allow the client time to collect her thoughts
B) Prompt the client to give a response
C) Offer the client a suggestion for a goal

A) Allow the client time to collect her thoughts

*Slowed response time is common in client’s with depression. Allow the client time to comprehend and formulate an answer.

A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take?
A) Encourage the parents to avoid discussing the death
B)
A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

A) It’s easier to talk about my feelings now.
B) Thank you for always taking such good care of me.
C) Suddenly I have enough energy to do whatever I want.

A) It’s easier to talk about my feelings now.

**Expressing feelings is the goal of treatment and a positive treatment outcome.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A) Orient the client to person, place & time.
B) Assist the client with deep breathing exercises
C) Calm the client by using therapeutic touch

B) Assist the client with deep breathing exercises
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this conditon?

A) The client needs excessive external input to make everyday decisions
B) The client has difficulty starting new relationships unless he feels accepted

A) The client needs excessive external input to make everyday decisions
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

A) Emotional lability
B) Self-sacrificing
C) Suspicious of others

A) Emotional lability

*The rapid transition from one emotion to another-out of proportion to the circumstances.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
A) Moderate
B) Mild
C) Severe
B) Mild

*This is when they can concentrate still and process information.

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following should the nurse include in the plan?
A) Admin. phenytoin 30min prior
B) Instruct the client to expect a headache after
C) Monitor the client’s cardiac rhythm during the procedure
C) Monitor the client’s cardiac rhythm during the procedure

*The seizure induced ECT can stress the heart. Monitor the heart.

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

A) Raise the pitch of the voice when speaking to the client
B) Interview the client in a private setting
C) Ask the client to complete a questionnaire

B) Interview the client in a private setting

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Post Author: Arnold

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