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Pré-visualização | Página 1 de 3A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for her deceased partner. Which of the following actions should the nurse take? Move the client to a room near the nurses’ station Limit visitors until the client is oriented to her environment Tell the client that her partner is deceased Talk with the client about activities she enjoyed with her partner A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client’s morning lithium level is 1.5 mEg/L. Which of the following laboratory findings should the nurse report to the provider? Erythrocyte sedimentation rate 18 mm/hr Hemoglobin 15 g/dL Serum T45 mcg/dL Sodium level 125 mEq/L A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching? Fear of abandonment Motor and verbal tics Hostile behavior Language delay A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take? Tell the client that the voices do not really exist Touch the client to help reduce his anxiety Instruct the client to go to a quiet room when he hears voices Ask the client what the voices are saying A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about the relapse should the nurse include? Additional acute episodes of depression are unlikely following inpatient care Early identification of changes, such as decreased social involvement, is important Medication compliance will prevent further need for inpatient hospitalization It is helpful to regularly reinforce to the client that things will get better A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? The client recently lost a grandparent in a MVA The clients town was hit by a tornado The clients youngest son is leaving for college The client is ambivalent about her upcoming retirement A charge nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following information should the nurse include in the teaching? Client confidentiality applies until the client dies Privileged communication protects nurse-to-nurse communication The duty to protect third parties requires a nurse to testify about a client The right to treatment ensures individualized care A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestation’s should the nurse expect? Sedation Rhinorrhea Bradycardia Hyperthermia A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? “you may notice an increase in saliva while taking this medication” “you may experience difficulties with sexual functioning while taking this medication” “you should expect an improvement in symptoms of depression in 3 to 4 days.” “you may notice a temporary ringing in the ears when starting this medication” A nurse who is working on a mental health unit should recognize that which of the following are indications for the use of electroconvulsive therapy (ECT)? Select all that apply. A client who is suicidal and in need of rapid treatment A client who has recently been diagnosed with severe depression A client who has bipolar disorder with rapid cycling A client who has mania and has not responded to medication therapy A client whose depression is secondary to situational difficulties A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client’s partner report to the provider? Obsessive attention to detail Inability to sleep Reports of fatigue Isolation from others A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? Diarrhea Heavy menstrual bleeding Tachycardia Orthostatic hypotension A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first? Recommend the client shave her hair Suggest wearing a scarf to cover her hair Discuss the importance of hair with the client Provide information on resources for obtaining a wig A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first? Inform the client that her admission is confidential Introduce the client to other clients in the day room Assist the client in facilitating behavioral change Determine coping strategies that the client has used in the past A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? A school-age girl who has bruises on her knees An older adult client who is bedbound and has a stage IV pressure ulcer An adolescent who has a vaginal candida infection A young adult who is pregnant and has a sprained ankle A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the nurse? “Succinylcholine will enhance the therapeutic effects of this treatment.” “Succinylcholine is given to reduce muscle movements during therapy.” “Succinylcholine will decrease the anxiety level that you might experience with this treatment.” “Succinylcholine is used as a general anesthetic to make sure you are sleeping during the A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for dextroamphetamine. Which of the following instructions should the nurse include in the teaching? “You should expect your child to gain weight while taking this medication.” “Administer the first dose of medication to your child 30 minutes before breakfast.” “You should expect your child to have diarrhea while taking this medication.” “Administer the last dose of medication to your child 6 hours before bedtime.” A community health nurse is planning an education program about depressive disorder. Which of the following factors should the nurse include as increasing the risk for depression? Male gender Hyperthyroidism Substance use disorder Being married A nurse in a provider’s office is collecting a health history from the parent of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the parent is the priority for the nurse to report to the provider? Reduced appetite Fatigue Dark urine Sweating A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? Do not administer the lorazepam Request a prescription for IV lorazepam Request that another nurse attempt to administer the lorazepam Place the lorazepam in the client’s food A nurse in an acute mental facility s receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? A client who does not recognize familiar people A client who cannot verbalize his needs A client who is awake and disoriented at night A client who is experiencing delusions of persecution A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the Página123 |
A nurse is caring for a client with ADHD who has recently started taking lithium
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