Mental health 2

1. A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions
should the nurse plan to take?

A. Ask the client to create her own schedule of daily activities.

B. Teach the client to use passive communication when interacting with others.

C. Determine the client’s need for assistance with grooming.

D. Limit the client’s involvement in unit activities.

2. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to
concentrate. Which of the following responses should the nurse make?

A. "It sounds like you're having a difficult time."

B. "Have you talked to your parents about this yet?"

C. "Why do you think you are so anxious?"

D. "How long has this been going on?"

3. A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the
medications at specific intervals when at home. Which of the following instructions should the nurse include in the
teaching?

A. "You really shouldn't change the schedule we established here in the facility."

B. "Let's work together to devise a time schedule that is convenient for you on a daily basis."

C. "We'll have to talk to your provider about switching to an alternative schedule."

D. "It doesn't really matter what time you take your medications as long as you don't skip any doses."

4. A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the
following hallucinations is the priority for the nurse to address?

A. Visual hallucination

B. Gustatory hallucination

C. Command hallucination

D. Tactile hallucination

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5. A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following
statements should the nurse make?

A. “Antidepressants are not your solution, but this therapy group is.”

B. “I notice you keep clenching your fists. This needs to stop.”

C. “You need to work hard on resolving conflict with those closest to you.”

D. “Let’s discuss what you mean when you say that you cannot ever return to work.”

6. A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean
clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?

A. "Everyone feels better after showering."

B. "You must be getting better. You look great!"

C. "I see you have done some grooming today."

D. "Why are you all dressed up today? Is it a special occasion?"

7. A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse
expect?

A. Expressive affect

B. Associative looseness

C. Echolalia

D. Ambivalence

8. A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality
disorder. Which of the following is the priority intervention for the nurse to make?

A. Promote appropriate behavior during group therapy sessions.

B. Encourage client input in the treatment plan.

C. Communicate with the client using concrete language.

D. Demonstrate assertive behavior.

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9. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should
the nurse expect?

A. Hand tremors

B. Stuporous level of consciousness

C. Bradycardia

D. Hypotension

10. A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate
to the nurse a potential risk for suicide? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

11. A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should
the nurse include to determine how the use of alcohol affects the client’s psychosocial behaviors?

A. "Has alcohol use affected your performance at work?"

B. "Have you received prior treatment for substance use disorder?"

C. "Do you receive treatment for any mental health disorders?"

D. "At what age did you begin drinking alcohol?"

12. The nurse is reviewing the client’s medical record. Based on the information, which of the following actions should
the nurse take?For each potential action, click to specify if the potential action is anticipated or
contraindicated for the client.

Answers cannot be displayed for this alternate item format.

13. A client states, "I just don't know what to do about my partner's drinking. Every time I see him drinking beer, I start
to feel extremely anxious." Which of the following is the most therapeutic response by the nurse?

A. "Tell me more about what is going on with your son. Is he still causing problems for you?"

B. "At one time you told me you were drinking regularly with your partner. Are you continuing to do that?"

C. "The next time your partner starts drinking, what is something you might do to decrease your anxiety?"

D. "I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another
person's drinking."

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14. A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following
actions should the nurse take?

A. Act to the client as if the hallucination is real.

B. Instruct the client to argue with the voices that are a part of the hallucination.

C. Ask the client direct questions about the hallucination.

D. Tell the client that the hallucination is not a part of reality.

15. For each potential provider's prescription, click to specify if the potential prescription is anticipated,
nonessential, or contraindicated for the client.

Answers cannot be displayed for this alternate item format.

16. A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How
many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)

______ mL

17. A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How
many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.)

______ mL

18. The nurse is assessing the client on day 10 of hospitalization. Click to highlight the information that indicates
the client’s treatment plan is effective.

Answers cannot be displayed for this alternate item format.

19. A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day, and the next day
refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of the following
defense mechanisms?

A. Repression

B. Splitting

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C. Sublimation

D. Undoing

20. A nurse in a community clinic facility notices a change in a client’s behavior. Which of the following manifestations
is the priority for the nurse to report?

A. Onset of command hallucinations

B. Development of magical thinking

C. Development of a diminished affect

D. Onset of anergia

21. A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the
following responses should the nurse make first?

A. "What are the voices telling you?"

B. "How often do you hear the voices?"

C. "I know you hear the voices, but I do not."

D. "The voices are part of your illness."

22. A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass
index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

23. A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as
risk factors for suicide? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

24. A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer’s disease.
The nurse notes that the client’s partner appears exhausted. He states that he is finding it more and more difficult
to care for his wife. Which of the following interventions is the nurse’s priority?

A. Recommend that the partner place the client in a long-term care facility.

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B. Suggest that the partner see a counselor to help him cope with his exhaustion.

C. Ask the partner to talk about his difficulties in caring for the client.

D. Tell the partner to call a family meeting to get help.

25. A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for
bupropion. Which of the following statements by the client indicates understanding of the teaching?

A. "I may develop a slow heartbeat while taking bupropion."

B. "I can drink one glass of wine with dinner each day while taking bupropion."

C. "I may not notice a lifting of my mood for at least 2 weeks."

D. "I should watch for increased salivation and drooling while taking bupropion."

26. A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to
help her feel better. Which of the following responses should the nurse make?

A. "Yes, I understand that you feel better wearing your bracelet."

B. "Why do you think the copper helps with your arthritis?"

C. "Believing objects have powers to make you feel better has no scientific basis."

D. "I think you should rely more on your medication therapy than on your bracelet."

27. A nurse is preparing to administer selegiline for a client who is admitted with major depression. Which of the
following actions should the nurse take?

A. Apply to dry skin on the client’s upper thigh.

B. Administer subcutaneously in the client’s abdomen using a 27 gauge needle.

C. Give the medication orally at bedtime to promote sleep.

D. Inject the medication intramuscularly in a large muscle.

28. A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping
strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

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29. A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the
following actions should the nurse include in the plan?

A. Monitor the client’s respirations every 4 hr.

B. Administer an antacid with the medication to decrease nausea.

C. Weigh the client daily.

D. Monitor the client for signs of bleeding.

30. A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently
complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should
the nurse take?

A. Talk to the client and identify the specific limits that are required of the client's behavior.

B. Discuss the problem in a community meeting with the other clients on the unit present.

C. Escort the client to her room each time the nurse observes the client socializing with other clients.

D. Tell the other clients to ignore the client's lies.

31. A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should
the nurse expect?

A. Hyperactive bowel sounds

B. Bradycardia

C. Hypertension

D. Dental erosion

32. A nurse in a mental health facility is caring for a client in the busy facility dining room during lunchtime when
suddenly the client becomes angry and throws a chair. Which of the following interventions should the nurse
perform first?

A. Restrain the client to prevent injury to himself or others.

B. Place the client in a monitored seclusion room until he is calm.

C. Administer a PRN antianxiety medication.

D. Attempt to talk the client down.

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33. A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients
should the nurse identify as having a risk factor for a suicide attempt?

A. A client whose family visits him weekly from out of town.

B. A client who usually acts impulsively.

C. A pregnant female client who is at 6 months gestation.

D. A client who attends religious services at the mental health facility

34. A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his
relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention
by the nurse?

A. "Tell me about the concerns that you have regarding your relationship."

B. "You should try to see your partner’s point of view before your own."

C. "We could develop a plan for how to talk about this with your partner."

D. "Relationship difficulties are stressful and require effort to resolve."

35. A nurse is assessing the client for manifestations of anorexia nervosa. Which of the following findings should the
nurse expect?Select all that apply.

Answers cannot be displayed for this alternate item format.

36. A nurse is discussing stress management techniques with a group of clients. Which of the following techniques
mentioned by a client should the nurse recognize as the least effective?

A. "I journal when I find it difficult to talk."

B. "I pray when I begin to breathe fast."

C. "I fix myself a pot of coffee when I get anxious."

D. "I exercise when my neck is tense."

37. A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss.
Which of the following should be the priority nursing intervention?

A. Determine the presence and degree of suicidal risk.

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B. Assist the client to identify negative effects of chemical dependency.

C. Identify support groups in the community for long-term treatment.

D. Refer the client to a mental health care provider for evaluation and treatment.

38. A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died.
Which of the following should the nurse recognize as an adaptive defense mechanism?

A. The client begins reading a book when he experiences hand tremors in response to loud noise.

B. The client makes a decision to postpone a needed surgery.

C. The client focuses on discussing his daily routine when asked about the fire.

D. The client develops stomach pains when fire is seen on television.

39. A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements
by the newly licensed nurse indicates an understanding of the teaching?

A. "The courts might require me to discuss confidential information."

B. "I am required to provide confidential information to insurance companies."

C. "If questioned during a police investigation, I am required to divulge confidential information."

D. "I am legally allowed to discuss confidential information with the client's former therapist."

40. The nurse is planning care for the client. For each potential nursing action, click to specify if the potential
action is anticipated, nonessential, or contraindicated for the client.

Answers cannot be displayed for this alternate item format.

41. A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on
rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following
actions should the nurse take?

A. Tell the client that it is unlikely that he has bone cancer.

B. Ask the client why he thinks the pain isn't a result of hiking.

C. Suggest genetic testing so the client can understand his risks.

D. Explain that the provider will see him and determine a course of action.

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42. A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia.
Available is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

______ tablet(s)

43. A nurse is caring for an older adult client who had a cerebrovascular accident and has left-sided weakness. The
client’s partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the
following responses should the nurse make?

A. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable."

B. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today."

C. "Don't worry. Most clients like your partner start making progress after a few days of rest."

D. "You will have to speak to the provider for that information. I can arrange that for you."

44. A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of
pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset
and frightened. Which of the following actions should the nurse take?

A. Assist the client to the correct room.

B. Place the client in restraints.

C. Reorient the client to time and place.

D. Move the client to a room at the end of the hall.

45. A nurse is caring for a client who has dementia due to Alzheimer’s disease and was admitted to a long-term care
facility following the death of her partner of 40 years. The client states, “I want to go home; my husband is waiting
for me to cook dinner.” Which of the following responses by the nurse is appropriate?

A. “This is where you live now.”

B. “This is a safer place for you to live.”

C. “Tell me what you like to cook for dinner.”

D. “Your family said there is no one to care for you at home.”

46. A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The parents tell the nurse

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they have taken their son’s name off the list for little league baseball next season. Which of the following
responses should the nurse make?

A. "It must be frustrating for you to have to cancel an activity your son enjoyed."

B. "Baseball can be a dangerous sport for children anyway."

C. "You never know. He could be ready for baseball by the spring."

D. "Why did you feel you needed to do that at this time?"

47. A nurse is planning care for a client who has a new prescription for wrist restraints due to violent behavior. Which
of the following actions should the nurse plan to take?

A. Check the client's need for toileting every 2 hr.

B. Ask the client if they need fluids every 1 hr.

C. Ensure the provider assesses the client within 60 min of restraint application.

D. Use a square knot to secure the wrist restraint.

48. Check the 6 assessment findings that require immediate follow-up.

Answers cannot be displayed for this alternate item format.

49. A nurse manager is providing staff education about working with clients who have a history of anger and
aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

50. A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client’s parents are
tearful and express feelings of guilt. Which of the following statements should the nurse make?

A. "You said that you feel guilty about your daughter’s diagnosis. Let’s talk about what is causing you to feel this
way."

B. "You should not feel guilty about your daughter’s diagnosis. Schizophrenia is unpreventable."

C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she
receives the proper treatment."

D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's
diagnosis?"

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51. A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the
following should be the nurse's approach?

A. Sit with the client and offer simple, direct information.

B. Have the client attend group therapy immediately.

C. Explain the unit policies to the client and answer any questions he might have.

D. Take the client on a tour of the unit and introduce him to all the staff members on duty.

52. A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the
following findings indicates the client is at risk for suicide?

A. The client has begun playing basketball with several other clients during the past month.

B. The client identifies with problems expressed by other clients.

C. he client's behavior has become impulsive in the past few weeks.

D. The client states she wants to go home to be with her children and partner.

53. A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse
expect?

A. A dismissal of past failures

B. Psychomotor agitation

C. An increase in energy

D. Sleep disturbances

54. A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following
findings supports the admitting diagnosis of acute mania?

A. The client’s spouse reports that client has recently gained weight.

B. The client is dressed in all black.

C. The client responds to questions with disorganized speech.

D. The client reports that voices are telling him to write a novel.

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55. A nurse is planning to administer haloperidol to a client who has acute psychosis. The nurse should monitor the
client for which of the following findings as an adverse effect of the medication?

A. Excess salivation

B. Increased agitation

C. Diarrhea

D. Dystonia

56. Drag words from the choices below to fill in each blank in the following sentence.

Answers cannot be displayed for this alternate item format.

57. A nurse is teaching the parents of a school-age child who has ADHD about atomoxetine. Which of the following
instructions should the nurse include in the teaching?

A. "Limit caloric intake to prevent excessive weight gain."

B. "Avoid crowds due to the increased risk for infection."

C. "Expect hyperactivity as a common adverse effect."

D. "Give the dose in the morning to help prevent insomnia."

58. A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of
the following actions should the nurse take to promote client communication?

A. Invite a family member to be present for the nursing history.

B. Provide basic wound care for obvious physical injuries.

C. Probe the client to offer a factual account of the abuse.

D. Be direct and honest when speaking with the client.

59. The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include?

Answers cannot be displayed for this alternate item format.

60. A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following

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interventions should the nurse include in the client's plan of care?

A. Provide a stimulating environment.

B. Have consistent unit routines.

C. Discourage daytime napping.

D. Schedule daily seclusion times.

61. A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the
client is experiencing maladaptive grief?

A. The client joined a bowling league 2 months ago.

B. The client has kept his partner's closet untouched since her death.

C. The client exercises at a local health facility 3 days each week.

D. The client meets his daughter for dinner every week.

62. A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries
following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her
caregiver. Which of the following nursing responses should the nurse manager make?

A. "I can arrange for a female assistive personnel to do your personal hygiene care."

B. "The nurse assigned to care for you is very capable and cares for other women in this situation."

C. "Your doctor is a man, so it seems like this should not be a problem."

D. "I can review the assignments and arrange for a female nurse to care for you."

63. A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania.
Which of the following client prescriptions should the nurse realize is expected to reduce the client’s mania?

A. Fluvastatin

B. Carbamazepine

C. Lorazepam

D. Propranolol

64. A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches

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should the nurse take?

A. Maintain a nonjudgmental attitude.

B. Avoid displaying an emotional response.

C. Offer sympathetic support.

D. Verbalize disapproval of the client's substance abuse.

65. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

66. A nurse is caring for a client who has a serum lithium level of 2.0 mEq/L. Which of the following is the priority
action for the nurse to take?

A. Notify the primary provider the result indicates toxicity.

B. Continue to monitor this expected maintenance level.

C. Request the provider increase the client’s medication dose.

D. Check the client for manifestations of hypernatremia.

67. A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client
indicates understanding of the goals of treatment?

A. "I plan to sit on a park bench for a few minutes each day."

B. "I can try participating in group therapy every week."

C. "I will join a book club in my neighborhood."

D. "I should avoid entering elevators and other closed spaces."

68. A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical
concepts when the client refuses to drink a between meal protein and calorie supplement?

A. Autonomy

B. Beneficence

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C. Veracity

D. Fidelity

69. A nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize
as a maladaptive defense mechanism?

A. A client slams a drawer after misplacing her wallet.

B. A man buys his partner a gift after flirting with his secretary.

C. A client forgets to schedule needed appointments when fearing chemotherapy.

D. A client ignores the thought of pain when scheduled for oral surgery.

70. A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which
of the following adverse effects of haloperidol?

A. Extrapyramidal symptoms

B. Fever

C. Intractable hiccups

D. Excessive salivation

71. A nurse in the emergency department is planning care for a client who is admitted for an overdose of
phencyclidine (PCP). Which of the following actions should the nurse plan to take?

A. Administer warmed IV fluids to counteract hypothermia.

B. Reverse the toxicity with naloxone.

C. Verbally attempt to calm the client.

D. Administer ammonium chloride.

72. A nurse is caring for a client who has a depressive disorder. The client states, “I just can’t feel any happiness or
joy in life.” Which of the following terms should the nurse use when documenting this finding?

A. Anhedonia

B. Anergia

C. Anosognosia

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D. Akathisia

73. A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the
following statements should the nurse recognize as an example of effective communication among family
members?

A. "If you keep saying that, I will tell everyone what you did last night."

B. "She is always bossing me around. Should she do that?"

C. "Can you tell me the reason you get upset each time I go to the mall?"

D. "Please do not raise your voice at the children. I am the one who left dishes in the sink."

74. A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is
the highest priority?

A. Protecting the client from injury

B. Determining the cause of the client's anxiety

C. Ensuring that the client feels safe

D. Identifying the client's coping skills

75. A nurse is caring for a client admitted to a mental health facility who asks, “Can I refuse the electroconvulsive
therapy (ECT) treatment scheduled for tomorrow?” Which of the following should be the nurse’s response?

A. "You have given signed consent for the treatments after they were explained to you."

B. "You will feel better after the course of treatments."

C. "You can refuse them, but the provider believes they are necessary."

D. "You have the right to refuse even though the consent form has been signed."

76. A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements
should the nurse make?

A. "You should be aware that excessive sleeping is an early sign of relapse."

B. "Relapse is an indication that you are not taking your medications properly."

C. "You should keep your provider’s and therapist’s number with you."

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D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."

77. For each client assessment finding, click to specify if the finding is a potential risk for suicide or a
protective factor against suicide.

Answers cannot be displayed for this alternate item format.

78. A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For
which of the following clients should the nurse withhold the medication and notify the provider immediately to have
clozapine therapy discontinued?

A. A client who has a WBC of 2,900 cells/mm3

B. A client who has a hematocrit of 55%

C. A client who has a serum potassium of 3.3 mEq/L

D. A client who has a BUN of 22 mg/dL

79. A nurse is caring for a client who has schizophrenia. The client states, “The government is forcing thoughts into my
brain through satellites.” The nurse should document that the client is experiencing which of the following types of
delusions?

A. Persecution

B. Control

C. Erotomanic

D. Somatic

80. A nurse in a mental health facility is preparing to interview a client who is has schizophrenia. Which of the
following actions should the nurse take?

A. Sit on the other side of a table from the client.

B. Place the client in a chair higher than the nurse.

C. Start the interview with a question the client can answer with a "yes" or "no."

D. Sit beside the client rather than facing him.

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81. A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions
should the nurse include in the plan? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

82. Which of the following 6 assessment findings require immediate follow-up?

Answers cannot be displayed for this alternate item format.

83. A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged
with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which
of the following factors that may cause lithium toxicity?

A. Experiencing diarrhea

B. Exercising moderately

C. Increasing sodium intake

D. Drinking green tea

84. A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of
the following is an expected finding?

A. Sleeping 12 hr or more each day.

B. Increasing sense of attachment to others.

C. Constant need to talk about the event.

D. Increasing feelings of anger.

85. A nurse is admitting a client to an alcohol abuse program. The client states, "I’m here because of my boss. It was
part of my job to go to parties and drink with clients." The client’s statement is an example of which of the following
defense mechanisms?

A. Reaction-formation

B. Compensation

C. Rationalization

D. Suppression

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86. A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should
the nurse identify as a primary risk factor for this disorder?

A. Recent history of stressful, positive life events.

B. Past history of childhood trauma.

C. Being an only child.

D. Having elevated levels of serotonin.

87. A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her
mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse
should anticipate planning care for managing which of the following phobias?

A. Xenophobia

B. Acrophobia

C. Mysophobia

D. Agoraphobia

88. A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client
asks which birth control method the nurse would recommend. Which of the following responses should the nurse
make?

A. "It's your choice, of course, but birth control pills are the most reliable."

B. "Your provider usually recommends a diaphragm and spermicidal cream."

C. "I'd consider an intrauterine device. You won't have to worry about pregnancy."

D. "Let's talk about the available options and go from there."

89. A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which of the
following statements indicates that the newly hired nurse understands when a tertiary intervention is needed?

A. "I should perform screenings to identify clients at risk for suicide."

B. "I should recognize the lethality of the suicide plan."

C. "I should provide counseling for the family following the suicide of a client."

D. "I should provide a safe environment to prevent the client from committing suicide."

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90. Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

91. A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by
the newly licensed nurse indicates an understanding of this condition?

A. "Postpartum depression usually begins 48 hours after childbirth."

B. "It's common for clients who have postpartum depression to exhibit psychotic behavior."

C. "The most common manifestation of postpartum depression is harming the infant."

D. "Postpartum depression is more likely to occur in women who have a history of depression."

92. Select 4 findings indicate that the client is experiencing serotonin syndrome.

Answers cannot be displayed for this alternate item format.

93. A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following
findings should the nurse expect?

A. Rapid speech

B. Chills

C. Distorted perceptual field

D. Urinary frequency

94. A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a
sign of cognitive distortion?

A. "I like to cut my food into small pieces."

B. "I really need to get into shape."

C. "If I eat one piece of candy, I may as well eat ten."

D. "I can't afford to gain weight."

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95. A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression.
Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

96. A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I
am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?

A. "It sounds frightening to feel like both God and the devil at the same time."

B. "I don't understand. Can you tell me what that means?"

C. "Are you saying that you are both good and bad?"

D. "There is no gate for me to open."

97. A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanoate 100mg/mL
for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest hundredth.
Use a leading zero if it applies. Do not use a trailing zero.)

______ mL

98. A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to
the nurse, “I’m being kept in this prison against my will. Please try to get me out.” Which of the following responses
should the nurse make?

A. "Why do feel that you need to leave?"

B. "You feel that you don’t belong here?"

C. "We are here to help you and give you the care that you need right now."

D. "Try to take some deep breaths and I’m sure you’ll feel better."

99. A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is
the highest priority?

A. Vitamin deficiency

B. Diaphoresis

C. Tremors

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D. Illusions

100.A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client’s medical
record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?

A. Offer to make arrangements for the Sacrament of the Sick

B. Prepare to stay with the client’s body after death until family arrives.

C. Arrange for a member of the client’s faith to bathe the body after death.

D. Post a sign on the client’s door stating, “No Talking”.

101.The nurse needs assistance to perform multiple tasks at this time. For each task, click to specify if the task is best
delegated to a licensed practical nurse (LPN) or an assistive personnel (AP).

Answers cannot be displayed for this alternate item format.

102.A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following
statements should the nurse include in the teaching?

A. "Administer the medication at bedtime."

B. "Your child might gain weight while taking this medication."

C. "This medication might increase the amount of saliva your child produces."

D. "Restrict your child’s intake of caffeine while she is taking this medication."

103.A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five
speeding tickets in the past 6 months. Which of the following interventions should the nurse take?

A. Make a contract with the client not to drive over the speed limit.

B. Call the local police and alert them to the client’s car license plate number and the make and model of her
car.

C. Ask the client to “hand over the keys” to you, and tell her that now she must use a cab or other public
transportation until your next session.

D. Inform the client that she cannot drink and drive.

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104.A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The
nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the
following? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

105.A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to
school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical
activities at school. Which of the following responses should the nurse make?

A. "Tell me more about how you are feeling about your son's activities."

B. "You might want to use tutors to home-school him."

C. "I agree. His well-being is the most important."

D. "You sound overprotective. Let's talk about this some more."

106.A nurse is discussing ageism with a newly licensed nurse. Which of the following statements by the newly
licensed nurse indicates an understanding of the concept?

A. "Ageism refers to a higher level of respect that Eastern cultures give to their elders."

B. "Ageism refers to the stereotype that older adults are not able to understand new information."

C. "Ageism refers to assumptions about an older adult client based on gender and economic status."

D. "Ageism refers to the increase in physical care required by older adults."

107.A nurse is reviewing the medical histories of four clients. Which of the following clients may develop
extrapyramidal symptoms from medication therapy?

A. A client who is in the third trimester of pregnancy and taking iron supplements.

B. An older adult client who has pancreatitis and is taking enzymes.

C. A client who has schizophrenia and is taking antipsychotic medication.

D. An adult client who has type 2 diabetes mellitus and is taking insulin.

108.A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse
identify as an example of secondary intervention?

A. Providing support for family and friends following a suicide

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B. Identifying individuals who are at higher risk for attempting suicide

C. Recognizing the warning signs of suicide

D. Performing life-saving measures following a suicide attempt

109.A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse
should include which of the following data? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

110.A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following prescriptions
should the nurse clarify with the provider? For each potential provider's prescription, click to specify if the
potential prescription is anticipated, nonessential, or contraindicated for the client.

Answers cannot be displayed for this alternate item format.

111.A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living
anymore." Which of the following responses should the nurse make?

A. "Of course people care. Your family comes to visit every day."

B. "Why do you feel that way?"

C. "Tell me who you think doesn't care about you."

D. "I care about you, and I am concerned that you feel so sad."

112.During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the
following client statements demonstrates the maladaptive use of regression?

A. “I wrote a short story about a heroic woman when I was really mad at my boss.”

B. “I don’t care about work anymore since I was not given a promotion.”

C. “I mentally separate myself from distractions around me when I paint on canvas.”

D. “I still cannot remember the scene of my husband's car accident.”

113.A client who is having burn debridement states, “You are the worst nurse I have ever seen. All you do is hurt me.”
Which of the following responses should the nurse make?

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A. "That’s a hurtful thing to say."

B. "Tell me more about that."

C. "Why would you say such a thing?"

D. "Well, that’s your opinion."

114.A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of
the following responses should the nurse make?

A. Ask him to describe what he is feeling.

B. Give the client some reading material as a distraction.

C. Suggest that he take a walk around the unit.

D. Refer him to the pastoral care team.

115.Which of the following 5 assessment findings require immediate follow-up?

Answers cannot be displayed for this alternate item format.

116.Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

117.For each potential nursing action, click to specify if the action is anticipated or contraindicated for the
client.

Answers cannot be displayed for this alternate item format.

118.A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following
information should the nurse include in the teaching?

A. Temporary memory loss is the most common adverse effect of ECT.

B. Medications are given to prevent seizure activity during ECT.

C. The greatest risk of ECT is brain damage.

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D. ECT is effective in the treatment of substance use disorders.

119.A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there
before she died." Which of the following statements should the nurse make?

A. "We will call your family in time for them to get here."

B. "I wonder if you are fearful of dying alone."

C. "I will make sure a staff member is in your room at all times."

D. "I will tell your family of your concern so that they can be here."

120.A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am
expecting a high level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and
we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's
response considered therapeutic?

A. It clearly articulates what is expected of the client.

B. It demonstrates empathy towards the client.

C. It sets limits on the client's manipulative behavior.

D. It uses reflection when talking with the client.

121.A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am
going to do. I cannot think right now." Which of the following actions should the nurse take?

A. Identify other housing options and sources of transportation.

B. Notify the facility chaplain to request scheduling an appointment.

C. Confirm that everything will be all right because belongings can be replaced.

D. Maintain eye contact with client and summarize the client's feelings.

122.A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the
following instructions should the nurse include in the client’s discharge plan?

A. Contact the crisis counselor once a week.

B. Identify anxiety-producing situations.

C. Try to repress feelings of anxiety.

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D. Eliminate stress and anxiety from daily life.

123.A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings
should the nurse expect?

A. Weight gain

B. Dependent edema

C. Nightmares

D. Bradycardia

124.A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following
responses is an indication the client is in the denial phase of the grief process?

A. "The doctor has been so good to me. I know he has tried everything he can. It is just my time."

B. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!"

C. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my
medication."

D. "Even though I am not hurting right now, I don’t feel like I have the energy to get out of bed."

125.A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy
(ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following
responses should the nurse make?

A. "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory
loss."

B. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced
seizure."

C. "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to
be certain this does not happen."

D. "The most common side effects are directly related to the use of anesthesia."

126.A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates
understanding of a relapse prevention plan?

A. “I can remember when my hallucinations first began.”

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B. “I know which of my hallucinations trigger a relapse.”

C. “I record the number of hallucinations I have each day.”

D. “I will read as much information as I can about schizophrenia.”

127.Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

128.A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches
the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the
following responses should the nurse make?

A. "Most clients with anxiety issues benefit from lying down."

B. "Come with me to an area where we can talk without interruption."

C. "Providers usually recommend relaxation exercises for clients who are as upset as you are."

D. "An antianxiety pill works best for situations like this."

129.A nurse is providing discharge teaching to a client who is taking risperidone. Which of the following instructions
should the nurse include in the teaching?

A. "Avoid becoming overheated while taking this medication."

B. "This medication may increase your blood pressure."

C. "Flu-like symptoms are an expected adverse effect of this medication."

D. "Muscle twitches can occur the first few weeks while taking this medication."

130.A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates
concrete thinking?

A. “I am aware that each problem has only one solution.”

B. "I am a prophet of the most high king."

C. “The voices tell me that I must avoid large crowds.”

D. “I know that you and the other nurses are trying to poison me.”

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131.A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following
resources will provide the most effective support immediately following the incident?

A. Psychologist

B. Close friend

C. Social worker

D. Chaplain

132.A nurse is teaching a client about adverse effects of zolpidem. Which of the following adverse effects should the
nurse include in the teaching?

A. Daytime sleepiness

B. Nighttime sweating

C. Change in taste

D. Double vision

133.A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the
following is an expected finding?

A. Death of client's father two months ago

B. Experiences frequent facial tics

C. Suspended from school several times in the past year

D. Adheres strictly to routines

134.A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions
should the nurse take? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

135.A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up
and down his right arm. Which of the following actions should the nurse take first?

A. Implement the client’s behavioral modification plan.

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B. Document the size and location of the cuts.

C. Inspect the cuts for debris.

D. Administer a tetanus antitoxin.

136.A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, “I don’t
care what the doctors say, there is no way I can have HIV, and I don’t need treatment for something I don’t have.”
The nurse identifies that the client is experiencing which of the following types of crisis?

A. Adventitious

B. Internal

C. Maturational

D. Situational

137.A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse,
"I should have died because I am totally worthless." Which of the following responses should the nurse make?

A. "You have a great deal to live for."

B. "It's not unusual for depressed people to feel that way."

C. "Why do you feel you are worthless?"

D. "You've been feeling that your life has no meaning."

138.A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the
nurse prepare to administer?

A. Methadone

B. Disulfiram

C. Risperidone

D. Lithium carbonate

139.A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep
confidential information about the desire to kill several classmates and a school teacher. Which of the following
responses by the nurse is appropriate to give?

A. "Because you are a minor, I have to share any information that I feel is important with your parents."

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B. "I cannot promise that. I must share this information with other members of the team who are responsible
for planning your care."

C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between
us."

D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

140.A nurse is preparing to administer amantadine 150 mg PO every 12 hr. Available is amantadine 50 mg/5 mL
syrup. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.)

______ mL

141.A nurse in a long-term care facility is caring for a client who has Alzheimer’s disease. Which of the following
actions should the nurse include in the plan of care?

A. Post a written schedule of daily activities.

B. Use an overhead loudspeaker to announce events.

C. Provide a consistent daily routine.

D. Allow the client to choose free-time activities.

142.A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the
nurse expect? (Select all that apply)

Answers cannot be displayed for this alternate item format.

143.Which of the following findings in the client’s medical record are consistent with antisocial personality disorder?
Click to highlight the findings that are consistent with antisocial personality disorder. To deselect a finding, click
on the finding again.

Answers cannot be displayed for this alternate item format.

144.The nurse is assessing the client during a follow-up visit. Which of the following findings indicate a therapeutic
response to the treatment plan?

Answers cannot be displayed for this alternate item format.

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145.A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the
following statements should the nurse include in the teaching?

A. "Dementia is characterized by a sudden onset of confusion."

B. "An altered level of consciousness is associated with dementia."

C. "The signs of dementia are progressive and irreversible."

D. "Dementia can be triggered by a high fever or dehydration."

146.A nurse is providing teaching to a client who has schizophrenia and is to begin taking haloperidol. Which of the
following information should the nurse include in the teaching?

A. "You may experience dizziness upon standing while taking this medication."

B. "This medication will decrease your symptoms of OCD."

C. "This medication may cause excessive salivation."

D. "You can stop taking the medication if the adverse effects are bothersome."

147.A nurse is discussing the care of a client who has a conversion disorder with persistent aphasia with a newly
licensed nurse. Which of the following statements should the nurse include about conversion disorder?

A. Conversion disorders are consciously triggered.

B. The condition may relapse within a year.

C. Testing for a pathophysiological cause of aphasia is not necessary.

D. Clients with conversion disorder have a flat affect.

148.A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. Which of
the following is an expected finding?

A. Family history of Alzheimer’s disease.

B. Personal history of alcohol use disorder.

C. Undergoing current treatment for HIV.

D. Current rehabilitation for opiate addiction.

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149.A nurse is planning discharge for a client who has borderline personality disorder. Which of the following
interventions should be included for this client?

A. Dialectical behavior therapy

B. Behavioral contract

C. Bibliotherapy

D. Safety plan

150.A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the
following clients should the nurse determine needs to be seen by a provider immediately?

A. A client who is taking olanzapine and experiences dizziness when first standing up

B. A client who is taking chlorpromazine and reports vomiting twice

C. A client who is taking thioridazine and has daytime drowsiness

D. A client who is taking clozapine, and has flu-like manifestations

151.A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following
statements indicates an understanding by the newly licensed nurse?

A. "Evidence must exist prior to reporting."

B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it.”

C. "I don’t want to defame someone if the report is false."

D. "If suspicion of abuse exists then reporting is mandatory.”

152.A nurse is teaching a community education course about the physical complications related to substance use
disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?

A. Alcohol

B. Caffeine

C. Cocaine

D. Inhalants

153.A client who has major depressive disorder states to the nurse that he and his family would be better off if he

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were gone. Which of the following is the nurse's priority response?

A. "Do you really think your family would be better off without you?"

B. "Are you thinking of harming yourself?"

C. "Tell me what is happening right now."

D. "When did you first start feeling this way?"

154.A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching
television. Suddenly one of the clients jumps up screaming and runs out of the room. Which of the following
actions should the nurse take?

A. Ask the group what they think about the client’s behavior.

B. Follow the client to determine the cause of the behavior.

C. Ignore the incident because it is an attention-seeking behavior.

D. Stay with the group and ask another client to go and check on the situation.

155.A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the
following actions should the nurse take?

A. Set limits for the relationship

B. Promote the use of transference by the client

C. Instruct the client on how he should behave.

D. Engage in friendly interactions with the client.

156.A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information
should the nurse identify as placing the client at risk for self-harm behaviors?

A. The client has borderline personality disorder.

B. The client has a parent who has dependent personality disorder.

C. The client has a history of bulimia nervosa.

D. The client recently received a promotion at work.

157.A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I’m

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feeling sad. I don’t want to talk now." Which of the following responses should the nurse make?

A. "It will help you feel better if you talk about it."

B. "I’ll come back when you feel like talking."

C. "I’ll stay with you a few minutes."

D. "Coming with me to the day room will take your mind off your troubles."

158.A nurse is providing a community health education class about suicide prevention. Which of the following should
the nurse identify as risk factors for suicide? (Select all that apply).

Answers cannot be displayed for this alternate item format.

159.A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has
been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should
the nurse take?

A. Prepare for gastric lavage due to an extremely elevated lithium level.

B. Administer the morning dose of lithium.

C. Check the client's medication record to assess whether the client has been refusing her lithium.

D. Hold the medication and assess for early manifestations of toxicity.

160.A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should
be included in the plan of care?

A. Rotate staff assignments for this client.

B. Use touch to calm the client during periods of anxiety.

C. Check the client's mouth after the client takes medication.

D. Assign an assistive personnel to feed the client at mealtimes.

161.A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment
should the nurse set up in the room prior to the treatment? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

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162.A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates
the ethical concept of autonomy?

A. Encouraging client feedback about satisfaction with the facility experience

B. Explaining unit rules and policies regarding unacceptable behaviors

C. Supporting the client's wish to refuse prescribed medications

D. Making sure the client understands expectations for client participation

163.A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just
prior to admission. Which of the following actions should the nurse take?

A. Discuss self-defense techniques with the client.

B. Inform the client photographs of injuries are required for a police report.

C. Ask the client to describe the situation.

D. Give the client a bed bath prior to physical examination.

164.A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I
don't know what I will do if they find I have cancer." Which of the following responses should the nurse make?

A. "Why do you think you might have cancer when your diagnosis is a benign condition?"

B. "I'm looking at your chart here and I don't see any reason for you to worry about that."

C. "I think that's something you need to discuss with your provider."

D. "I'm hearing that you are concerned that it might turn out that you have cancer."

165.A nurse is planning care for a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the
following medications should the nurse anticipate administering prior to the procedure?

A. Diphenhydramine

B. Atropine

C. Epinephrine

D. Fluoxetine

166.A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the

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following statements by the client indicates understanding of the teaching?

A. "I should expect relief from depression within 3 to 4 days."

B. "I will take my fluoxetine at bedtime so I can sleep better."

C. "I should notify my provider if I develop a skin rash."

D. "I will notice an improvement in my sex drive."

167.A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia.
Which of the following components should the nurse include? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

168.A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a
prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for
lithium toxicity?

A. The client runs 4 miles outdoors every afternoon.

B. The client drinks 2 liters of liquids daily.

C. The client eats 2 to 3 gm of sodium-containing foods daily.

D. The client eats foods high in tyramine.

169.A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the
following information should the nurse include in the teaching?

A. "Notify the provider if pregnancy is desired or suspected."

B. "This medication may increase your blood pressure."

C. "Breast tenderness may occur with this medication."

D. "You can double the dose of medication if you feel anxious."

170.A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). Which of the following
statements indicates an understanding of the teaching?

A. "I will be awake during the procedure."

B. "I will undergo treatments for one year."

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C. "My memory loss will last several minutes after treatment."

D. "I will be monitored closely for seizure activity."

171.A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should
the nurse expect?

A. Tremors

B. Hypothermia

C. Hypotension

D. Respiratory depression

172.A nurse is teaching about electroconvulsive therapy (ECT) with a newly licensed nurse. The nurse should identify
that the newly licensed nurse understands the teaching when she states that ECT treats which of the following
disorders?

A. Narcotic addiction

B. Vegetative depression

C. Personality disorder

D. Eating disorder

173.A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which
of the following statements should the nurse include in the teaching?

A. "You will need to consume a low-salt diet while on this medication."

B. "You will need your blood levels drawn weekly during the first month."

C. "You will need to take this medication on an empty stomach."

D. "You will need to stop this medication if you experience diarrhea."

174.Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Answers cannot be displayed for this alternate item format.

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175.A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states
that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect
diagnostic testing for which of the following medical conditions?

A. Pancreatitis

B. Cholecystitis

C. Tuberculosis

D. Hypothyroidism

176.A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the
following statements by the client indicates he is ready for discharge?

A. "Right now, I can’t bathe or dress myself, but that’s not important."

B. "When I get home, I’m going to let the people who put me here know how I angry I am."

C. "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."

D. "Taking care of myself is important, but it’s okay if I want to take a break and not do anything."

177.A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years.
Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

A. Shuffling gait

B. Constant tapping of feet when sitting

C. Sudden onset of high fever

D. Twisting tongue movements

178.Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Answers cannot be displayed for this alternate item format.

179.A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client
can be kept in the hospital after the 72-hr hold is over for which of the following conditions?

A. The client is a danger to herself or others.

B. The client is unwilling to accept that treatment is needed.

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C. The client states that she does not like the neighbor.

D. The client states that she plans to move out of the state immediately.

180.A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client
is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A. Honk the car horn to get the client’s attention.

B. Calmly speak the client’s name out of the car window.

C. Keep driving in a path that is going away from the client’s house.

D. Stop the car in the client’s driveway and call the authorities.

181.A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of
the following statements should the manager include in the discussion?

A. "Clients should be given medications even if they refuse them."

B. "The laws regarding restraints are different for clients who are admitted involuntarily."

C. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary."

D. "Clients who are involuntarily admitted have the right to informed consent."

182.A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the
nurse interpret as displaying manic behavior? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

183.A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and
aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him.
Which of the following responses should the nurse make?

A. "So, it seems that you feel responsible for what happened to your mother."

B. "Your mother will be fine. You shouldn't worry so much."

C. "Why do you blame yourself? You could not have prevented the stroke."

D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."

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184.Which of the following items in the client’s medical record indicate that they are a candidate for electroconvulsive
therapy (ECT)?

Answers cannot be displayed for this alternate item format.

185.A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing
action?

A. Remain with the client.

B. Provide a diverting activity.

C. Encourage verbalization of feelings.

D. Instruct the client to remember past coping mechanisms.

186.A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and
weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect?
(Select all that apply.)

Answers cannot be displayed for this alternate item format.

187.A nurse is reviewing the medical record of a client who has a new prescription for clozapine for the treatment of
schizophrenia. Which of the following findings indicates a contraindication to clozapine?

A. Asthma

B. Fasting blood glucose 120mg/dL

C. WBC count 3,300/mm3

D. Hypertension

188.A community mental health nurse is assessing a client who has schizophrenia. Which of the following findings
indicates the client might be relapsing?

A. The client reports difficulties with sleeping and concentrating.

B. The client states he has started smoking again.

C. The client is wearing mismatched clothing.

D. The client reports feelings of anger toward her provider.

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189.A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse
implement to establish therapeutic relationships with the clients?

A. Provide sympathy during interactions.

B. Focus on the words of the clients.

C. Control the pace of establishing the nurse-client relationships.

D. Demonstrate genuineness when communicating.

190.A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to
shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the
client is prohibited in the nurse’s job description. Which of the following is an appropriate nursing response?

A. "I won’t be able to shop for you today because I have to get home to my family."

B. "I would be happy to do whatever I can to help you."

C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then."

D. . "Let’s look at some other resources to solve this problem."

191.A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following
actions should the nurse identify as the priority?

A. Lock the doors to the unit and secure windows so they cannot be opened.

B. Provide the client with plastic eating utensils for meals.

C. Remove any objects from the client’s environment that could be used for self-harm.

D. Assign a staff member to stay with the client at all times.

192.Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.

Answers cannot be displayed for this alternate item format.

193.The nurse is reviewing the client’s medical record. Which of the following prescriptions should the nurse
anticipate the provider prescribing?For each potential provider's prescription, click to specify if the potential
prescription is anticipated or contraindicated for the client.

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Answers cannot be displayed for this alternate item format.

194.A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse
recommend for group therapy?

A. A client who has been taking amitriptyline for 3 months for depression

B. A client exhibiting psychotic behavior

C. A client admitted 12 hr ago for acute mania

D. A client who is experiencing alcohol intoxication

195.A nurse is caring for a client who is taking amitriptyline. The nurse should monitor for which of the following
adverse effects?

A. Orthostatic hypotension

B. Drooling

C. Diarrhea

D. Metallic taste in mouth

196.A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the
nurse take?

A. Inform the client of consequences.

B. Speak slowly in a low, calm voice.

C. Forbid the client from speaking in an abusive manner.

D. Remain a distance of 1 ft away from the client.

197.A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following
behaviors should alert the nurse that the adolescent still has suicidal intent?

A. Telling his parents that he doesn’t want to talk about the suicide attempt.

B. Stating that he wants to be with his peers more than with his parents.

C. Preferring to eat his meals while watching TV.

D. Planning to give his CD collection to his girlfriend.

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198.A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with
a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very
depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

A. Speak to the provider about adding an MAOI to the current medication regimen.

B. Explain that antidepressants often take several weeks to be fully effective.

C. Tell the client that the provider will need to change citalopram to a different medication.

D. Recommend a sleep study be done on the client.

199.A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is
worried about the adverse effects of the treatment. Which of the following responses should the nurse make?

A. "I will have your provider discuss the adverse effects with you before the treatment begins."

B. "Someone from the American Cancer Society will be here soon to answer your questions."

C. "What is it about the adverse effects that concern you?"

D. "I agree. Sometimes the adverse effects can be worse than the disease."

200.Complete the following sentence by using the lists of options.

Answers cannot be displayed for this alternate item format.

201.A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current
activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of
the following actions should the nurse take?

A. Ask the client if she has a plan to commit suicide.

B. Recognize the attempt at manipulation and escort the client back to her activity.

C. Assist the client to her room and allow her to rest before resuming activity.

D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

202.A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission
from the nurse before performing activities of daily living. This behavior indicates which of the following findings to
the nurse?

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A. The client is ready for discharge.

B. The client may be having a recurrence of delirium tremens.

C. The client is able to function independently.

D. The client is exhibiting dependency.

203.A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of
the following findings should the nurse identify as an adverse effect of olanzapine?

A. Weight gain of 3 lb in 2 weeks

B. Delusions of grandeur

C. Heart rate 60/min

D. Oral candidiasis

204.A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following
clients should the nurse suggest offering the therapy to?

A. Post-traumatic Stress Disorder

B. Schizophrenia

C. Pedophilia

D. Paranoid personality disorder

205.A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission
to an acute mental health facility. Which of the following statements should the nurse include?

A. "You will give up your right to refuse antidepressant medications upon admission."

B. "Your provider is required to notify your employer of your admission."

C. "You will still need to give informed consent for treatments after admission."

D. "You cannot leave the facility until your provider completes a discharge summary."

206.A nurse is teaching a client who plans to take St. John's wort to treat her depression. Which of the following
information should the nurse include in the teaching?

A. "You should avoid driving when taking St. John’s wort because it can cause doziness."

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B. "You may experience vivid dreams while taking St. John’s wort."

C. "St. John’s wort may increase your risk of developing oxalate kidney stones."

D. "St. John’s wort may cause gastrointestinal irritation."

207.A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following
manifestations should the nurse identify as negative symptoms? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

208.A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the
following medications should the nurse expect to administer to the client?

A. Diazepam

B. Acamprosate

C. Naltrexone

D. Disulfiram

209.A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse
expect?

A. Prior physical health followed by the need for two surgeries within the last three months.

B. Obsession over a fictitious defect in physical appearance.

C. Sudden unexplained loss of peripheral sensation.

D. Constant worry about the undiagnosed presence of an illness.

210.A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information
should the nurse include when discussing clients' cultures?

A. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care.

B. Nonverbal communication is important in few cultures.

C. Culture plays no role in determining when a client will seek medical care.

D. Nurses should expect clients to adapt to the care provided regardless of culture.

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211.A nurse is planning care for a client who has a prescription for alprazolam. For which of the following adverse
effects should the nurse plan to monitor?

A. Decreased urine output

B. Manifestations of seizure activity

C. Inability to recall events

D. Increase in white blood cell count

212.Which of the following findings in the client's medical record indicates the client has bulimia nervosa?Click to
highlight the findings in the client's medical record that indicate the client has bulimia nervosa. To deselect a
finding, click on the finding again.

Answers cannot be displayed for this alternate item format.

213.A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder.
Which of the following interventions should the nurse identify as the priority?

A. Helping the client identify positive personality traits

B. Providing for adequate hydration and rest

C. Confronting the use of denial and other defense mechanisms

D. Educating the client about the consequences of alcohol misuse

214.A nurse is providing teaching to the parents of an adolescent who has a depressive disorder and a new
prescription for trazodone. Which of the following information should the nurse include in the teaching?

A. "Trazodone can cause suicidal thoughts in adolescents."

B. "Expect your child to lose weight while taking trazodone."

C. "Your child’s symptoms of depression should improve within one week."

D. "Trazodone should be taken in the morning to prevent insomnia."

215.A nurse is providing care for a client who seems anxious following a recent tragedy. Which of the following
statements by the client reflects an adaptive use of sublimation?

A. "I will work out in the gym every time I get mad about what happened."

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B. "I do not have anxiety, and I’m not sure why you think I do."

C. "I can’t remember anything that happened, but I am okay."

D. "I’m not capable of moving past this time in my life."

216.A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for
a vitamin B6 deficiency?

A. A client who takes gabapentin as part of treatment phenytoin for a seizure disorder.

B. A client who has asthma.

C. A client who has chronic alcohol use disorder.

D. A client who takes heparin to prevent deep vein thrombosis.

217.A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a
specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

A. “I need to make sure that the potential victim is warned.”

B. “I need to keep the information confidential due to the client’s right to privacy.”

C. “I can only discuss the client’s threats with a court order.”

D. “I should verbally report this information to the psychiatrist.”

218.A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements
by a staff member indicates an understanding of the teaching?

A. “The legal requirement for client confidentiality ceases if the client is deceased.”

B. “Staff members are required to divulge information to attorneys if they call for information.”

C. “Health care workers are not required to answer a court’s requests for information about a client’s
disclosure.”

D. “Providers are required to warn individuals if the client threatens harm.”

219.A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and
malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

A. Enroll the client in a nutritional class on the unit.

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B. Weigh the client at the same time every morning.

C. Ask provider to arrange a consultation with the facility chaplain.

D. Sit with the client during meals and snacks.

220.A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout
angrily at the clients around her. Which of the following actions should the nurse take first?

A. Call for assistance to place the client in restraints.

B. Escort the client to an unlocked seclusion room.

C. Offer the client a PRN antianxiety medication.

D. Speak to the client calmly, giving simple directions.

221.For each potential provider's prescription, click to specify if the potential prescription is anticipated,
nonessential, or contraindicated for the client.

Answers cannot be displayed for this alternate item format.

222.A nurse is caring for a client who has bipolar disorder. The client states, “I feel like Superman. I can do anything. I
can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting?

A. Flight of ideas

B. Grandiosity

C. Reality testing

D. Derealization

223.A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the
nurse include in the teaching?

A. "Decrease your fluid intake to 1 liter per day."

B. "You might produce extra saliva while taking this medication."

C. "Notify your provider if you experience vomiting or diarrhea."

D. "Take the medication on an empty stomach."

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224.A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected
finding?

A. Frequent manic episodes.

B. Refusal of medication due to paranoia.

C. Preoccupation with manifestations of various illnesses.

D. Involuntary loss of a sensory function.

225.A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The
client sits quietly and calmly in the examination room and states, "I’m fine." The nurse should recognize the
client’s behavior as which of the following reactions?

A. Denial

B. Displacement

C. Projection

D. Undoing

226.A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they
are trying to poison my food." Which of the following statements should the nurse make?

A. "You are mistaken. Nobody is lying about you or trying to poison you."

B. "You seem to be having very frightening thoughts."

C. "Why do you think you are being lied about and poisoned?"

D. "Who is lying about you and trying to poison you?"

227.A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic
response to the treatment plan

Answers cannot be displayed for this alternate item format.

228.A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the
following responses should the nurse make?

A. “Perhaps you should discuss this with your physician.”

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B. “Of course you aren’t going to die, at least not in the immediate future.”

C. “I recommend you exercise daily and avoid smoking to decrease your risk.”

D. “Tell me more about these fears of dying from a heart attack.”

229.A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the
clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun
of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?

A. Magical thinking

B. Delusions of grandeur

C. Ideas of reference

D. Looseness of association

230.A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the
clients is experiencing delirium?

A. A client wants to know the current time while there is a clock on the wall.

B. A client attempts to climb out of bed and repeatedly states she must get home.

C. A client requests extra blankets when the thermostat in the room indicates 25.6&deg C (78&deg F).

D. A client refuses to get out of bed and has no motivation to attend to daily hygiene.

231.A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who
suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should
recognize that which of the following adverse effects may be occurring?

A. Tardive dyskinesia

B. Neuroleptic malignant syndrome

C. Acute dystonia

D. Pseudoparkinsonism

232.A nurse educator is discussing community mental health with a group of nursing students. Which of the following
sites should the educator identify as a source of secondary prevention?

A. Day care center

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B. Outpatient rehabilitation center

C. Community recreational center

D. Crisis center

233.A nurse on the hospice unit is caring for a newly-admitted client. Which of the following client statements should
the nurse report to the provider?

A. "I am getting a little sleepy after I take my pain medication."

B. "I would go to church every day if it meant getting more time."

C. "I cannot wait to meet my creator when it is my time."

D. "I plan to take an antiaging supplement to prolong my life."

234.A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the
following is the priority nursing intervention?

A. Administering an anticonvulsant.

B. Padding side rails to prevent injury.

C. Preparing for artificial ventilation.

D. Applying a cooling blanket.

235.A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following
nursing approaches is therapeutic to include in the client's plan of care?

A. Encouraging decision-making

B. Giving the client choices of activities

C. Playing a game of chess with the client

D. Spending time sitting with the client

236.A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales
should the nurse complete prior to administering the first dose of risperidone?

A. The Abnormal Involuntary Movement Scale

B. The Hamilton Depression Scale

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C. The Body Attitude Test

D. The Recovery Attitude and Treatment Evaluator

237.A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should
the nurse expect?

A. Significant change in weight

B. Hyperexcitability

C. Exaggerated response to stimuli

D. Attention seeking behavior

238.A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions
should the nurse take?

A. Compliment the client for weight gain.

B. Allow the client to eat at any time.

C. Provide privacy when friends visit.

D. Schedule regular weigh-in times.

239.A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following information
should the nurse include in the teaching?

A. “Use a reliable form of contraception while taking this medication.”

B. “If a dose is missed, double the next dose of medication.”

C. “This medication may increase your blood pressure.”

D. “Do not eat aged cheeses while taking this medication.”

240.A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the
nurse plan to take to create a therapeutic environment?

A. Plan to discuss any topic that is presented.

B. Focus on client weaknesses to increase adaptation.

C. Provide continuity of care by assigning the same staff.

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D. Allow client to determine the boundaries of the nurse-client relationship.

241.A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the
nurse expect?

A. Muscle aches and chills

B. Fatigue and depression

C. Anxiety and diaphoresis

D. Arrhythmia and respiratory depression

242.A nurse is teaching a community education course about the physical complications related to substance use
disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?

A. Acute pancreatitis

B. Slowed breathing

C. Nasal septum perforation

D. Permanent short-term memory loss

243.A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which
of the following should the nurse include in the teaching as manifestations seen in the moderate stage of
Alzheimer's disease? (Select all that apply.)

Answers cannot be displayed for this alternate item format.

244.A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The
client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of
the following complications should the nurse suspect?

A. Agranulocytosis

B. Neuroleptic malignant syndrome

C. Akathisia

D. Tardive dyskinesia

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245.Complete the diagram by dragging from the choices below to specify the following:Which condition the client is
most likely experiencingTwo actions for the nurse take to address this conditionTwo parameters for the nurse to
monitor to assess the client’s progress

Answers cannot be displayed for this alternate item format.

246.A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following
findings should indicate to the nurse that the client is ready to reintegrate into the unit?

A. The client's vital signs are within the expected reference range.

B. The client requests to use the bathroom.

C. The client eats all of the food provided for each of her meals.

D. The client follows directions.

247.A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation
with haloperidol. The nurse should assess the client for which of the following adverse effects?

A. Dysrhythmias

B. Cataracts

C. Pancreatitis

D. Bleeding

248.A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody,
and overly anxious. Which of the following is the nurse’s assessment priority?

A. Coping abilities

B. Support systems

C. Suicide risk

D. Psychiatric history

249.A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the
following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

A. Disclose some personal information to the client to demonstrate approachability.

B. Wait for the client to initiate interaction.

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C. Approach the client frequently throughout the day for brief interactions.

D. Adopt a neutral attitude when providing care.

250.A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use
disorder. Which of the following client goals is the highest priority?

A. The client will acknowledge alcohol dependence and need for treatment.

B. The client will rebuild damaged interpersonal relationships.

C. The client will implement alternative strategies for managing anxiety.

D. The client's withdrawal from alcohol will be managed without complications.

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