CJE

Question 1

A client and their partner come to the clinic stating they have been unable to have sexual intercourse. The female client states they have pain and their “vagina is too tight.” The client was raped at 15 years of age. Which nursing diagnosis is most appropriate for this client?
a. dysfunctional grieving related to loss of self-esteem because of lack of sexual intimacy
b. risk for trauma related to fear of vaginal penetration
c. vaginismus related to vaginal constriction
d. sexual dysfunction related to sexual trauma

Answer 1

d. sexual dysfunction related to sexual trauma

Sexual dysfunction is the nursing diagnosis that is the most appropriate. Dysfunctional grieving because of lack of intimacy is not correct as the couple may have emotional intimacy. The trauma occurred when the female client was 15 years of age and thus is not an acute problem. Vaginismus is a medical diagnosis.

Question 2

A child is being seen at the clinic for an attention deficit hyperactivity disorder (ADHD) assessment. What symptom(s) would the nurse expect to find? Select all that apply.
a. excessive climbing and running
b. excessive fidgeting
c. pouting behaviors
d. cannot wait to take turns
e. easily distracted

Answer 2

a, b, d, e

A child with ADHD will manifest excessive climbing and running, excessive fidgeting, inability to take turns, and distractibility. This child does not exhibit pouting or moody behaviors.

Question 3

Important teaching for a client receiving risperidone should include advising the client to:
a. maintain a therapeutic level by doubling a dose if the client misses a dose.
b. be sure to take the drug with a meal because it can severely irritate the stomach.
c. discontinue the drug if the client gains weight.
d. notify the health care provider if the client notices an increase in bruising.

Answer 3

d. notify the health care provider if the client notices an increase in bruising.

Bruising may indicate blood dyscrasias, so notifying the health care provider about increased bruising is very important. The client shouldn’t double the drug dose. This drug doesn’t irritate the stomach, and weight gain isn’t an adverse effect of risperidone therapy.

Question 4

A female client who is hospitalized for an eating disorder weighs 15 lb (6.8 kg) less than the ideal body weight. Which goal is a priority for this client?
a. attending all eating disorder support groups
b. eating bigger meals at breakfast
c. gaining 1 lb (0.5 kg) per week
d. reporting an improved self-image

Answer 4

c. gaining 1 lb (0.5kg) per week.

The actual desired weight gain of 1 lb (0.5 kg) per week is the most measurable goal for the client. Attending all eating disorder support groups is a goal, but it is not as important as actual weight gain. The client can eat a larger meal at breakfast and then not eat sufficient food and overexercise for the remainder of the day. The client’s improved self-image is important, but actual weight gain is the priority.

Question 5

A client who has lost control has been put into restraints. Which nursing intervention is the highest priority when a client is placed in restraints?

a. monitoring the client every 15 minutes
b. assisting with nutrition and elimination
c. performing range-of-motion exercises for each limb, one at a time
d. changing the client’s position every 2 hours

Answer 5

a. monitoring the client every 15 minutes.

Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client’s position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

Question 6

The nurse is about to administer lithium carbonate to a client with bipolar disorder in a mania state. What is the nurse’s action after assessing the client’s lithium level to be 1.0 mEq/L (mmol/L)?
a. Notify the health care provider.
b. Hold the lithium carbonate.
c. Administer the lithium carbonate.
d. Repeat the lithium level.

Answer 6

c. administer the lithium carbonate.

To treat acute mania, the client’s serum lithium level should be between 0.6 and 1.2 mEq/L (mmol/L). The serum lithium level shouldn’t exceed 2 mEq/L (mmol/L). The nurse must monitor the client continuously for signs and symptoms of lithium toxicity, such as diarrhea, vomiting, drowsiness, muscular weakness, ataxia, stupor, and lethargy. The nurse must also keep in mind that even a normal lithium level can become toxic. Notifying the health care provider of the normal level with a client in mania is not appropriate. There are no signs and symptoms of toxicity, so the medication should not be held. There is no reason to repeat the level.

Question 7

The parent of a young adult client diagnosed with schizophrenia is asking questions about their child’s antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching?
a. “If they experience restlessness or muscle stiffness, they should tell their health care provider (HCP).”
b. “I should give them benztropine to help prevent constipation from the ziprasidone.”
c. “If they become dizzy, I’ll make sure they don’t drive.”
d. “The ziprasidone should help them be more motivated and less withdrawn.”

Answer 7

b. “I should give them benztropine to help prevent constipation from the ziprasidone.”

Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the HCP. Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.

Question 8

A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which the client lost both legs. The client states, “I will never be able to work again or live a normal life.” Which responses by the nurse would be considered therapeutic? Select all that apply.

a. “Losing both legs is hard to accept, how are you feeling now?”
b. “With a prosthesis, you will be up and walking again soon.”
c. “You must be devastated with your loss. Have you sought legal advice?”
d. “The occupational therapist will teach the use of adaptive equipment promoting independence.”
e. “I am here to help you. Let’s devise a plan so that you are working toward your goals.”

Answer 8

a, d, e

Having a life-changing event frequently leaves individuals in a state of shock and overwhelmed with the situation. The client requires a supportive environment to meet the client’s recovery needs. Validating the client’s feelings and having the client express their feelings opens communication. Offering of self is another way to open communication and establish a trusting relationship. Setting mutually established client-centered goals allows the client to feel involved and in control of the rehabilitation process. An occupational therapist who is a member of the rehabilitation team will assist the client with adaptive devices which can promote independence. It is patronizing to state that the client will be up and walking soon. Although that may be a true statement, the client has still experienced a significant loss. Asking about legal advice is not the role of the nurse.

Question 9

The nurse is speaking with the parents of an adolescent diagnosed with bulimia nervosa. What condition(s) should the nurse tell the parents to monitor for in the adolescent? Select all that apply.
a. suicidal ideation
b. fluid and electrolyte imbalances
c. dental caries
d. mucosal melanoma
e. cardiopathies

Answer 9

a. suicidal ideation,
b. fluid and electrolyte
c. dental caries.
d. cardiopathies

An adolescent with bulimia nervosa is also at risk for dental caries and fluid and electrolyte imbalances, such as dehydration and hypokalemia related to frequent vomiting. Cardiomyopathies may also result from chronic electrolyte imbalances. Individuals who have bulimia nervosa are also at increased risk for suicide. The parents of an adolescent with bulimia should be prepared to monitor for signs and symptoms of these conditions and seek appropriate care as needed. Oral cancers like mucosal melanoma are not associated with bulimia.

Question 10

The nursing staff has finished restraining a combative client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which outcome?

a. Coordinate documentation of the incident.
b. Resolve negative feelings and attitudes.
c. Improve the use of restraint procedures.
d. Calm down before returning to the other clients.

Answer 10

c. improve the use of restraint procedures.

Although coordinating documentation, resolving negative feelings, and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.

Question 11

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, “I do not want you to contact my family. I don’t even have to talk to you.” Which statement is the most appropriate nursing response?
a. “I need you to trust me and the staff members in the facility.”
b. “It sounds like you are not concerned about your problems and why you are in the hospital.”
c. “This can just be between us, and I will share your progress only with the doctors and not your family.”
d. “Anything you say about your feelings is confidential but your care involves the whole team so we can all work together.”

Answer 11

d. “anything you say about your feelings is confidential but your care involves the whole team so we can all work together.”

Being truthful with the client and reinforcing the need for prevention of harm to self or others clarifies what the client can expect from the team. Challenging the client will contribute to a sense of low self-worth. “It sounds like you are not concerned about your problems and why you are in the hospital” is nontherapeutic and devalues the client’s self-perception. Negotiating a special agreement or luring the client into the interview will not be therapeutic. “I need you to trust me and the staff members in the facility” does not offer a therapeutic way to establish trust.

Question 12

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?
a. seizures
b. shivering
c. anxiety
d. chest pain

Answer 12

a. seizures

Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

Question 13

The nurse is providing care for a client admitted to the hospital for alcohol withdrawal symptoms. The client is now in the postrecovery phase of treatment, and the nurse is assessing for possible psychiatric complications related to the client’s long history of alcohol use disorder. What assessment question is most appropriate for the nurse to ask?
“Do you ever have thoughts of hurting yourself?” “Do you find it difficult to manage your time effectively?” “Have you ever been told you have a problem with managing anger?” “Did you have problems with compulsive thoughts or behaviors?”

Answer 13

a. “Do you ever have thoughts or hurting yourself?”

Psychiatric complications associated with alcohol use disorder include depression and suicidal ideations. Asking a direct question concerning the occurrence of thoughts of hurting themself would be appropriate. While obsessive-compulsive disorder, ineffective anger management, and poor time management can be observed in clients dealing with alcohol use disorder, none is directly associated.

Question 14

A client is in the emergency department with their partner. The client is just recovering from a temporary drug-induced psychosis from lysergic acid diethylamide (LSD). The client is still frightened and a little suspicious. Which nursing action is most appropriate?

a. having an unlicensed assistive personnel (UAP) stay with the client to decrease the client’s fear
b. placing the client next to the nursing desk
c. leaving the client alone until the “trip” is over
d. having the partner check on the client frequently

Answer 14

a. having an unlicensed assistive personnel (UAP) stay with the client to decrease the client’s fear

Having a UAP stay with the client provides reassurance and safety. Being next to the nursing desk will increase stimuli and confusion. Being alone will increase the client’s fears and anxiety. It is inappropriate to ask the partner to provide client supervision for the nurse.

Question 15

A client is admitted to a psychiatric unit after a suicide attempt. The client is withdrawn, has poor hygiene, and appears underweight. What is the priority for a nurse in keeping a therapeutic milieu for this client?
a. Encourage the client to participate in group therapy sessions.
b. Give the client structure and support until the client is able to function.
c. Validate a client’s worth and respect for life.
d. Manage the client’s spiritual needs.

Answer 15

b. give the client structure and support until the client is able to function.

The nurse’s priority for a client who has just entered the milieu of the psychiatric unit is to provide a client with safety and security. As the client progresses and displays less destructive behavior, the nurse will encourage the client to participate in group therapy. Validation is part of the actions of a nurse to establish the therapeutic milieu. The nurse will begin validation by giving the client respect and showing the client worth through the nurse’s actions. Management of the client’s spiritual needs is continuous within the therapeutic milieu; however, the client’s physical environment and physical needs are the priority.

Question 16

A client with bipolar disorder, manic phase, shows little interest in eating. What should the nurse do to help the client obtain recommended daily allowances of nutrients?
a. Give the client half of a meat and cheese sandwich to carry with them.
b. Inform the client that snacks are available only if they eat properly at mealtime.
c. Tell the client to sit alone at mealtime so that they will not be distracted by others.
d. Teach the client about proper nutrition.

Answer 16

a. give the client half of a meat and cheese sandwich to carry with them.

The best nursing intervention is giving the client finger foods high in protein and calories that they can eat while they pace or walk.
Informing the client that snacks are available if they eat properly at mealtime is inappropriate because the client is too busy and distracted to sit and eat an entire meal.
Telling the client to sit alone at mealtime to decrease distractions will not help them because the client is in a manic state, is easily distracted, and needs to move.
Teaching the client about proper nutrition ignores their need for adequate intake. The client would be unable to focus on the nurse’s teaching.

Question 17

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol, 10 mg by mouth twice per day. During a discharge teaching session, a nurse should provide which instruction to the client?
a. Take the medication 1 hour before a meal.
b. Decrease the dosage if signs of illness decrease.
c. Apply a sunscreen before exposure to the sun.
d. Increase the dosage up to 50 mg twice per day if signs of illness don’t decrease.

Answer 17

c. apply a sunscreen before exposure to the sun.

Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals — not 1 hour before — and should instruct the client not to decrease or increase the dosage unless a health care provider orders the change.

Question 18

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern?
a. alcohol use disorder
b. avoidance behavior
c. suicide potential
d. explosive outbursts

Answer 18

c. suicide potential

An unemployed client with a personal history of anorexia nervosa and a family history of affective disorders is at high risk for suicide. Although this client could be at risk for alcohol use disorder, the history indicates a strong risk of depression and suicide. Avoidance behavior is characteristic of clients diagnosed with an anxiety disorder, not anorexia nervosa. Explosive outbursts are associated with posttraumatic stress disorder and impulse control disorder.

Question 19

After the nurse teaches a client about lorazepam, which client statement(s) would indicate the need for further instruction? Select all that apply.
a. “I can chew sugarless gum if my mouth feels dry.”
b. ”I can adjust the dosage when I feel more anxious.”
c. “I shouldn’t drink alcohol.”
d. “I can take lorazepam with food if I get nauseous.”
e. ”I can stop taking lorazepam immediately if I need to.”

Answer 19

b. “I can adjust the dosage when I feel more anxious.”
e. “I can stop taking lorazepam immediately if I need to.”

Lorazepam, a benzodiazepine, is used as an antianxiety agent and depresses the central nervous system (CNS). Benzodiazepines cause physical dependence and tolerance and should never be stopped abruptly because withdrawal symptoms can occur. Slow tapering is required to minimize withdrawal symptoms.
The client should not adjust the dosage when feeling anxious because of tolerance and the possibility of overdose.
Common CNS adverse effects are drowsiness, fatigue, and incoordination. Other adverse effects such as dry mouth can be helped by rinsing the mouth and using sugarless gum and candy.
The drug can be taken with food if the client experiences nausea.
The use of alcohol and other CNS depressants can further CNS depression.

Question 20

The campus health nurse is caring for a client after they were sexually assaulted. Which of the following intervention would be most beneficial for this client?

a. Advise the client to take martial arts lessons.
b. Agree when the client states, “I should just move on.”
c. Explore the client’s strengths and resources with them.
d. Assess for negative coping behaviors.

Answer 20

c. explore the client’s strengths and resources with them.

The goal of crisis intervention is to support clients to resume pre-crisis levels of functioning. Variables in a client’s recovery include support and access to resources. Suggesting courses in martial arts could be a strategy, but more important for the client’s adjustment would be helping the client identify strengths and resources that could give them support. Assessing for coping should include all client activity, not only negative coping behaviors. Agreeing with the client that they should move on would be giving advice, a nontherapeutic technique.

Question 21

A nurse is assessing a client taking tranylcypromine sulfate. Which client statement requires immediate follow up from the nurse?
a. “I am taking my blood pressure regularly and recording it in my journal. Yesterday it was 137/76 mm Hg.”
b. “I accidentally cut my finger with a knife, and it took 2 hours to stop bleeding.”
c. “I have cut down on my intake of pickled herrings, sauerkraut, and liverwurst.”
d. “I will stop taking this medication 10 days before my gallbladder surgery.”

Answer 21

b. “I accidentally cut my finger with a knife, and it took 2 hours to stop bleeding.”

Clients taking tranylcypromine sulfate are at risk for thrombocytopenia. A cut that continues to bleed is a sign of low platelets. The nurse should immediately follow up and assess the client’s risk for bleeding. Clients on tranylcypromine sulfate are also at risk for a hypertensive crisis. Frequent monitoring of blood pressure is encouraged. Pickled herring, sauerkraut, and liverwurst are high in tyramine and increases the risk of hypertensive crisis and should be avoided. Although the nurse should follow up and assess how much of these foods the client is consuming, the priority is hemorrhage. If able, clients are instructed to stop taking this medication at least 10 days prior.

Question 22

When assessing a hospitalized client diagnosed with major depression and borderline personality disorder, the nurse should ask the client about which of the following first?
a. Access to pills and weapons.
b. Suicidal plans.
c. Suicidal thoughts.
d. Seriousness of the client’s intent to die.

Answer 22

c. suicidal thoughts.

The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

Question 23

A client takes lithium carbonate daily, and their most recent lithium carbonate level is 1.8 mEq/L. What response by the nurse is best for this client?
a. Tell the client to continue taking their lithium.
b. Tell the client to take half their dose of lithium and to follow up in 1 week.
c. Tell the client to hold their intake of lithium and to call the health care provider.
d. Instruct the client to switch to thioridazine instead of continuing their current therapy.

Answer 23

c. tell the client to hold their intake of lithium and to call the health care provider.

The doses of lithium carbonate are individualized based on a standardized safe level of 0.6 to 1.2 mEq/L. The client’s blood levels are higher than standards, although individual response and tolerance vary. The client should not proceed with the current treatment, and the practitioner needs to be contacted for orders to proceed or reduce the dose. Thioridazine is not interchangeable with lithium. Thioridazine is used for clients with schizophrenia and psychosis.

Question 24

The nurse plans care for a client who is being abused. Which measure is most important to include?
a. being compassionate and empathetic
b. teaching the client about abuse and the cycle of violence
c. explaining to the client their personal and legal rights
d. helping the client develop a safety plan

Answer 24

d. helping the client develop a safety plan.

The client’s safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care. Being empathetic, teaching about abuse, and explaining the person’s rights are also important after safety is ensured.

Question 25

A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client’s extrapyramidal symptoms?
a. benztropine
b. dantrolene
c. clonazepam
d. diazepam

Answer 25

a. benztropine

Benztropine is an anticholinergic administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine, is administered to reduce anxiety.

Question 26

The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity?
a. black tongue
b. increased tearing
c. constipation
d. persistent GI upset

Answer 26

d. persistent GI upset

Persistent GI upset indicates a mild to moderate toxic reaction that should be reported. Black tongue is an adverse reaction to mirtazapine (Remeron), not lithium. Increased tearing is not an adverse reaction to lithium. Diarrhea is more common with lithium than constipation.

Question 27

A client has catatonic behaviors. Which outcome would indicate a medication has been most effective in improving long-term behavior?

The client:

a. can move all extremities occasionally.
b. walks with the nurse to their room.
c. responds to verbal directions to eat.
d. initiates simple activities without directions.

Answer 27

d. initiates simple activities without directions.

Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. Moving all extremities occasionally, walking with the nurse to their own room, and responding to verbal directions to eat represent single steps toward the client initiating their own actions.

Question 28

A nurse plans to include the parents of a client with anorexia nervosa in the client’s therapy sessions. The nurse should anticipate that the parents will:
a. tend to overprotect their child.
b. have a history of substance use disorder.
c. maintain emotional distance from their child.
d. alternate between expressing love for and rejection of their child.

Answer 28

a. tend to overprotect their child

A client with anorexia nervosa typically comes from a family in which parents are controlling and overprotective and emphasize perfection and achievement. These clients use eating to gain control over one aspect of their lives. Parents of children with anorexia nervosa tend not to have a history of substance use disorder, maintain emotional distance, or alternate between expressing love and rejection.

Question 29

Which information is important for a nurse to include in a teaching plan for a client with schizophrenia who is taking clozapine?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the health care provider immediately.
c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.

Answer 29

b. report a sore throat or fever to the health care provider immediately.

A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the client’s WBC count drops below 3,000/μl, the medication must be discontinued. Clients taking this medication may experience hypotension. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The client should continue to take this medication even after symptoms have been controlled. If the medication must be discontinued, it should be slowly tapered over 1 to 2 weeks under the supervision of a health care provider.

Question 30

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement?

a. “I take my medication every morning before breakfast.”
b. “I’m constantly sick and feel like I always have a fever.”
c. “I’ve been exercising regularly and lost 5 pounds.”
d. “Sometimes I get dizzy if I stand up quickly.”

Answer 30

b. “I’m constantly sick and feel like I always have a fever.”

A major adverse reaction of risperidone is agranulocytosis. Therefore, it is a priority for the nurse to follow up if the client reports constantly being sick. Risperidone can be given without regard to meals; taking it at the same time every day is encouraged. Clients are encouraged to exercise regularly; the nurse should monitor the client taking risperidone for weight gain. Orthostatic hypotension is a common side effect of risperidone, and the nurse should follow up; however, the priority concern is agranulocytosis. Additionally, the client indicates experiencing dizziness “sometimes” but the feeling sick “constantly.”

Question 31

The nurse is providing discharge teaching to a client diagnosed with schizophrenia. Which client statement(s) would cause the nurse to intervene? Select all that apply.

a. “As soon as I start feeling like myself again, I’ll decrease my medications.”
b. “I should look for a mental health support group.”
c. “I’ll exercise 3 times a week and stop eating fast food.”
d. “If the voices come back, I’ll stay at home to ensure my safety.”
e. “I’ll call if I develop muscle twitches I can’t control.”

Answer 31

a. “As soon as I start feeling like myself again, I’ll decrease my medications.”
d. “If the voices come back, I’ll stay at home to ensure my safety.”

Clients diagnosed with schizophrenia should not stop or decrease their medications without the direction of a health care provider. Many antipsychotic medications require a constant dose to be effective. If a client diagnosed with schizophrenia begins to hear voices again, the client should call the health care provider to be seen. If the client indicates a lack of understanding of these ideas, the nurse needs to do further teaching.

A support group could be helpful, and exercising regularly and eating healthy are important. The client should contact the health care provider if involuntary muscle contractions occur, as this is a sign of dystonia, a side effect of antipsychotic medications.

Question 32

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis?
a. hypotension
b. tachycardia
c. hot, dry skin
d. constricted pupils

Answer 32

b. tachycardia.

Amphetamines, which are central nervous system stimulants, cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

Question 33

While collecting data on a client, the nurse observes symptoms that lead to a suspicion of opioid withdrawal. Which symptoms would the client exhibit? Select all that apply.

a. flushing
b. piloerection
c. nausea
d. vomiting
e. abdominal cramps
f. hypotension

Answer 33

a, flushing
b. piloerection
c. nausea
d. vomiting
e. abdominal cramps

Typical symptoms of opioid use disorder and withdrawal include flushing, piloerection, nausea, vomiting, abdominal cramps, increased lacrimation, rhinorrhea, and hypertension.

Question 34

A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL; 43.2 mmol/dL). The client later admits to drinking heavily for years. The client periodically reports tingling and numbness in the hands and feet. Which finding does the nurse expect based on these symptoms?
a. acetate accumulation
b. thiamine deficiency
c. triglyceride level of 300 mg/dL (3.39 mmol/L)
d. serum potassium level of 1.8 mEq/L (1.8 mmol/L)

Answer 34

b. thiamine deficiency.

Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation is unrelated to the client’s symptoms. The triglyceride level indicates buildup, but this is not related to the client’s symptoms. The serum potassium level is below normal, but it is unrelated to the client’s symptoms.

Question 35

The nurse is assessing a client for heroin use disorder. Which finding indicates the client has used heroin?

a. sclera red and bloodshot
b. pupils small and constricted
c. pupils large and dilated
d. drooping eyelids

Answer 35

b. pupil small and constricted.

Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance.

Question 36

A nurse is administering total parenteral nutrition (TPN) to a client hospitalized with severe anorexia nervosa. Which laboratory finding would alert the nurse to a potential problem?
a. elevated glucose levels
b. decreased magnesium level
c. elevated phosphate level
d. decreased CD4 cell counts

Answer 36

b. decreased magnesium level.

A decreased magnesium level indicates continued malnutrition problems; the prescribing health care provider or an advanced practice nurse would have to adjust the chemical composition of the TPN. Elevated glucose levels are expected in a client receiving TPN because of the high concentration of glucose being administered. A client with anorexia nervosa is at risk for a decreased, not elevated, phosphate level. A decreased CD4 cell count is a laboratory value associated with a diagnosis of human immunodeficiency virus or acquired immunodeficiency syndrome, not with a diagnosis of anorexia nervosa.

Question 37

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect:
a. a postoperative infection.
b. alcohol withdrawal.
c. septicemia.
d. alcohol hallucinosis.

Answer 37

b. alcohol withdrawal.

The client’s vital signs and hallucinations suggest alcohol withdrawal delirium or alcohol withdrawal syndrome. Although infection and septicemia may arise as postoperative complications, they wouldn’t cause this client’s signs and symptoms and would typically occur later in the postoperative course. Alcoholic hallucinosis, a rare complication of chronic alcohol use disorder is characterized by hallucinations that occur during a state of clear consciousness, typically beginning 24 hours after the last drink. Unlike the client in this scenario, the client with alcoholic hallucinosis does not have confusion or significant changes in vital signs; except in the most advanced stages, the client recognizes the hallucinations as unreal.

Question 38

A client is admitted to the emergency department with an elevated blood alcohol level. The authorities state the client was driving on the wrong side of the road. The client is transferred to the acute care unit where they awaken the next morning. Vital signs are stable, and the client has a headache. What action should the nurse take first when caring for this client?
a. Work through personal feelings related to substance use disorder.
b. Be persistent with the client regarding the substance use disorder.
c. Help to make abstinence and sobriety worthwhile for the client.
d. Suggest a treatment program within the client’s home area.

Answer 38

a. work through personal feelings related to substance use disorder.

The nurse must work through personal feelings related to substance use. Negative feelings towards individuals with substance use problems may make the nurse prejudiced against this client. Being persistent with the client regarding the substance use disorder, helping to make abstinence and sobriety worthwhile for the client, and suggesting a treatment program near the client’s home all are interventions that the nurse can accomplish after the initial approach to the client.

Question 39

A high school student is referred to the school nurse for suspected substance use disorder. Following the nurse’s assessment and interventions, what would be the most desirable outcome?
a. The student discusses conflicts over drug use.
b. The student accepts a referral to a substance use disorder counselor.
c. The student agrees to inform the parents of the problem.
d. The student reports increased comfort with making choices.

Answer 39

b. the student accepts a referral to a substance use disorder counselor.

All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance use disorder counselor.

Question 40

When assessing a client withdrawing from alcohol, the nurse notes that the client is anxious, experiencing nausea, is restless, and has a tremor when both arms are extended. What should the nurse do next?

a. Continue to assess the client.
b. Move the client to a quieter room.
c. Administer a benzodiazepine as prescribed.
d. Transfer the client to an acute care psychiatric unit.

Answer 40

c. administer benzodiazepine as prescribed.

The client is exhibiting signs and symptoms of withdrawal, and the nurse should administer the benzodiazepine to manage the anxiety, nausea, and restlessness and to prevent seizures. After administering the medication, the nurse will continue to assess the client and ensure the client is in a quiet environment. There is no need to transfer this client to the psychiatric unit based on the information provided.

Question 41

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client’s history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. The client is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?
a. initiating caloric and nutritional therapy as ordered
b. instituting behavioral modification therapy as ordered
c. addressing the client’s low self-esteem
d. monitoring vital signs and weight regularly

Answer 41

a. initiating caloric and nutritional therapy as ordered.

A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client’s low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client’s physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn’t take precedence over providing adequate caloric intake to ensure survival.

Question 42

A nurse is providing care to a client who was hospitalized for significant electrolyte imbalances. Further assessment revealed that the client engaged in binging behaviors followed by purging behaviors to prevent weight gain. After receiving treatment, the client is now being prepared for discharge. Which client statement indicates that the discharge teaching was successful?
a. “If I occasionally overeat, I can use a laxative to take care of it.”
b. “If I’m feeling down, it’s okay if indulge myself with ice cream.”
c. “I realize potato chips and candy bars are my triggers.”
d. “I should use an enema every week to keep my bowels regular.”

Answer 42

c. “I realize potato chips and candy bars are my triggers.”

Effective teaching is evidenced by the client’s statement about triggers. Knowing triggers can aid the client in making healthier choices and avoiding the stimulus for binging and purging. Although binging relapses can recur, it is not healthy, nor is it an appropriate coping method. Using food to cope with depression is also not a healthy coping mechanism. Laxatives and enemas are common means for purging, so their use should be avoided for this client.

Question 43

A client walks into the clinic and tells the nurse they have run out of money for crack and have crashed and they want something to help them feel better. Which factor is most important for the nurse to assess?
a. suspiciousness
b. loss of appetite
c. drug craving
d. suicidal ideation

Answer 43

d. suicidal ideation.

The nurse assesses the client for feelings of depression and suicidal ideation. After the client experiences an instantaneous high from crack, a crash immediately follows, and the client has an intense craving for more crack. A crash commonly leads to a cocaine-induced depression when additional crack is unavailable. At times, the depression is so severe that users attempt suicide. Although suspiciousness, loss of appetite, and drug craving are also associated with cocaine use, they are less of a priority than suicidal ideation.

Question 44

A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to:
a. avoid shopping for large amounts of food.
b. control eating impulses.
c. identify a connection between anxiety and eating behaviors.
d. restrict eating to three meals per day.

Answer 44

c. identify a connection between anxiety and eating behaviors.

Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn’t a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn’t a realistic goal early in treatment.

Question 45

A nurse is teaching the parents of an adolescent client diagnosed with anorexia nervosa about the treatment plan. Which statement by the parents indicates a need for additional teaching?
a. “We realize the first step in treatment is to get our child’s weight restored.”
b. “Our child’s view of themselves is less of an issue than their diet and exercise.”
c. “We’ll need to keep an eye on how much physical activity our child does.”
d. “We may need to watch our child eating meals at the beginning of treatment.”

Answer 45

b. “Our child’s view of themselves is less of an issue than their diet and exercise.”

Anorexia nervosa is a psychological disorder of self-imposed starvation resulting from a distorted body image and inability or refusal to maintain a normal weight. With this condition, the client’s self-view is altered and needs to be restructured. The client’s self-view is foundational to their issues with diet and exercise and is just as important to address as part of treatment. The primary goal is weight restoration with parents taking responsibility for ensuring that the adolescent eats sufficiently and limits pathologic weight-control behaviors (such as observing the adolescent during meals) as well as for meal planning and preparation. Initially, physical activity is limited and supervised but is gradually increased when weight gain and stabilization occur. Activity also should focus on enjoyable activities instead of goal-oriented ones.

Question 46

A hospitalized client craves a drink after withdrawing from alcohol. Which measure is the best way to help the client resist the urge to drink?
a. a locked-door policy
b. a routine search of visitors
c. one-to-one supervision by the staff
d. support from other clients with alcohol use disorder

Answer 46

d. support from other clients with alcohol use disorder.

Group support has proved more successful than individual attention from the staff in influencing positive behavior in clients with alcohol use disorder.
Locked doors do not help clients change their behavior or develop their own controls.
Searching visitors is impractical and externally oriented.
One-to-one supervision by staff is impractical and not as effective as a support group.

Question 47

An older adult client has been admitted to the hospital following a femoral fracture resulting from a fall. Two days after admission, the client has developed disorientation and agitation and is experiencing visual hallucinations. An assessment reveals no signs of infection or electrolyte disturbances. What aspect of the client’s health history should the nurse prioritize?
a. The client has been taking citalopram for treatment of depression for several months.
b. The client has a history of heavy alcohol intake.
c. The client was severely injured in a motor vehicle crash 18 months ago.
d. The client had a pacemaker implanted 3 years ago.

Answer 47

b. the client has a history of heavy alcohol intake.

Alcohol withdrawal can result in symptoms such as agitation, hallucinations, or delusions in the days following cessation of regular alcohol intake. In some cases, clients are not fully candid about alcohol intake before admission. Protective isolation would not normally result in sufficient sensory deprivation to cause sensory or cognitive disturbances. While the client’s pain is significant, it is not likely to cause sensory disturbances. Selective serotonin reuptake inhibitors, such as citalopram, are not associated with hallucinations and delusions, particularly when the client has been taking them long term.

Question 48

One of the goals for a client with anorexia nervosa is for the client to demonstrate increased individual coping by responding to stress in constructive ways. Which intervention will the nurse discuss with the client as the best way to work toward meeting the goal?
a. engaging in an enjoyable cardiovascular exercise daily
b. studying the practices of mindfulness and meditation
c. keeping a personal journal and discussing it with the nurse
d. connecting with family and friends through phone calls

Answer 48

c. keeping a personal journal and discussing it with the nurse.

The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress. Although physical activity can reduce stress, the client with anorexia is more likely to exercise to burn calories and lose weight. Although talks with friends can decrease stress, it does not help the client explore the sources of the stress. Through journaling and exploration, it may be determined that meditation is a goal to work toward in the future but this would be a premature first step.

Question 49

A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

a. barbiturates.
b. amphetamines.
c. methadone.
d. benzodiazepines.

Answer 49

c. methadone.

Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn’t have the same deleterious effects as opiates such as heroin and morphine or stimulants such as cocaine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and using these drugs would make further detoxification treatment necessary.

Question 50

A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client?
a. providing one-on-one supervision during meals and for 1 hour afterward
b. letting the client eat with other clients to create a normal mealtime atmosphere
c. trying to persuade the client to eat and thus restore nutritional balance
d. giving the client as much time to eat as desired

Answer 50

a. providing one-on-one supervision during meals and for 1 hour afterward.

Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward. Letting the client eat with other clients wouldn’t be therapeutic because other clients might urge the client to eat and give this client attention for not eating. Trying to persuade the client to eat would reinforce control issues, which are central to this client’s underlying psychological problem. Instead of giving the client unlimited time to eat the nurse should set limits and let the client know what is expected.

Question 51

An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober?
a. Give the client black coffee to drink.
b. Walk the client around the unit.
c. Have the client take a cold shower.
d. Provide the client with a quiet room to sleep in.

Answer 51

d. provide the client with a quiet room to sleep in.

The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not influenced by drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have the client sleep off the effects of the alcohol.

Question 52

A nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?
a. Restrict visits with family members until the client begins to eat.
b. Provide privacy for the client during meals.
c. Set up a strict eating plan with the client.
d. Encourage the client to exercise, to reduce anxiety.

Answer 52

c. set up a strict eating plan with the client.

Establishing a consistent eating plan and monitoring the client’s weight are important for treatment of this disorder. Because control issues play a central part in anorexia nervosa, clients are likely to be more compliant if they take part in developing the eating plan. The family should be included in the client’s care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

Question 53

The nurse is caring for an older adult client with a history of repeated hospitalizations for alcohol poisoning. Considering this client’s unique needs, what is the priority intervention for this client?
a. frequent reorientation to person, time, and place
b. monitoring for visual and auditory hallucinations
c. administration of prescribed antiemetic medication as needed
d. implementation of seizure precautions

Answer 53

d. implementation of seizure precautions.

Acute alcohol withdrawal is relatively rare in people younger than age 30, but the risk and severity increase with age. While the client is likely to experience hallucinations and confusion as well as nausea and vomiting, the priority is the management of seizures. The client’s age makes them more likely to experience a seizure, thus prioritizing seizure precautions. Of the options listed, seizures present the greatest risk to the client’s health.

Question 54

A client is voluntarily admitted to a substance use disorder unit. The client admits to drinking at least 1 qt (1 L) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings will the nurse document as evidence of alcohol withdrawal?
a. vomiting, watery frequent diarrhea, and pulse below 80 beats/minute
b. dehydration, temperature above 101°F (38.3°C), and pruritus
c. blood pressure of 90/50 mmHg, decreased appetite, and somnolence
d. pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness

Answer 54

d. pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness.

Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Dehydration and an elevated temperature may occur, but a temperature above 101°F (38.3°C) indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal.

Question 55

The nurse plans care for a client experiencing alcohol withdrawal. Which food should the nurse eliminate from the client’s diet?
a. milk
b. regular coffee
c. orange juice
d. eggs

Answer 55

b. regular coffee.

Regular coffee contains caffeine, which acts as a psychomotor stimulant and leads to feelings of anxiety and agitation. Serving coffee to the client may add to tremors and wakefulness. Milk, orange juice, and eggs are part of a well-balanced, high-protein diet needed by the client in alcohol withdrawal who is nutritionally depleted.

Question 56

A nurse is caring for a client with bulimia nervosa. Strict management of the client’s dietary intake is necessary. Which intervention is the most important?
a. Fill out the client’s menu and make sure the client eats at least half of what is on the tray.
b. Let the client eat meals in private. Engage the client in social activities for at least 2 hours after each meal.
c. Serve the client’s menu choices in a supervised area and observe the client 1 hour after each meal.
d. Let the client eat food brought by family, but have the client keep a strict calorie count.

Answer 56

c. serve the client’s menu choices in a supervised area and observe the client 1 hour after each meal.

Allowing the client to select food from the menu will help the client feel some sense of control. The client must eat 100% of what is selected. Remaining with the client for at least 1 hour after eating will prevent the client from purging. Bulimic clients should be allowed to eat only food provided by the dietary department.

Question 57

A 22-year-old client reports substernal chest pain and states that their heart feels like “it’s racing out of my chest.” The client reports no history of cardiac disorders. The nurse attaches the client to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage?
a. barbiturates
b. opioids
c. cocaine
d. benzodiazepines

Answer 57

c. cocaine

Because of the client’s age and negative medical history, the nurse would question about cocaine use. Barbiturate overdose may trigger respiratory depression and a slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and MI.

Question 58

Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)?
a. “You’ll be offered a strong sedative before the procedure.”
b, “This therapy will provide excellent symptom relief.”
c. “You may experience a complete loss of memory after the treatment.”
d. “You may experience a time of confusion after the treatment.”

Answer 58

d. “ You may experience a time of confusion after the treatment.”

The nurse should explain that the client may experience a time of confusion following ECT as a result of electricity passing through the cerebral cortex and disrupting nerve impulses. Although it’s true that the client will be offered a sedative, communicating this information isn’t an essential component of informed consent. It’s unrealistic to promise a client that the procedure will provide symptom relief. Complete memory loss isn’t an expected response to ECT.

Question 59

A client’s admitting diagnosis is schizophrenia with an episodic delusional disorder. The nurse applies what intervention strategy while working with the client in this pronounced delusional state?
a, Attempt to define and reinforce positive aspects of the client’s personality.
b, Address the client within a group so others may speak to the irrational delusion.
c. Focus on the client’s underlying feelings, and redirect inappropriate responses.
d. Discuss the consequences of responding to the delusional thoughts with the client.

Answer 59

c. focus on the client’s underlying feelings, and redirect inappropriate responses.

The work of the nurse is to support the client’s feelings and potential behaviors (for example, anxiety and restlessness) while offering coping techniques for these feelings. The nurse avoids exploring or trying to understand the delusions themselves. The goal of treating a delusional disorder is to increase client awareness of the delusion and to acknowledge the feelings the delusions places on the client. Reinforcing the positive aspects of the client’s personality does not help achieve this goal. One-on-one therapy is better than group therapy for establishing trust with a client experiencing delusions.

Question 60

An outpatient client with schizophrenia has been withdrawn from friends and family for 3 weeks. What is the most appropriate long-term goal for the client?
a. calling the client’s parent once a day
b. attending day therapy three times a week
c. allowing two friends to visit every day
d. remaining out of bed for 10 hours a day

Answer 60

b. attending day therapy three times a week

Attending day therapy three times per week is a long-term goal that will show the most progress in overcoming withdrawal. The client calling their parent is a first step in getting out of a severe withdrawal. Allowing two friends to visit every day would be appropriate if the client is successful with calling their parent once a day. Insufficient information is presented in the scenario to indicate that excessive sleep is a problem.

Question 61

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client?
a. thiamine deficiency
b. tardive dyskinesia
c. agranulocytosis
d. dystonic reaction

Answer 61

c. agranulocytosis

Clozapine has a potential side effect of agranulocytosis, which can develop suddenly or over a period of time. It is characterized by fever, malaise, a sore throat with ulcerations, and leukopenia. The drug must be immediately discontinued. It is important for the client to have weekly blood counts for 6 months of therapy and then every 2 weeks. Thiamine deficiency is exhibited by shortness of breath and other symptoms of congestive heart failure. Tardive dyskinesia is a side effect of antipsychotic medications and is characterized by lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Dystonic reactions are an extrapyramidal side effect characterized by spasms in several muscle groups.

Question 62

The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply.

a. “If I am having trouble sleeping or eating, I will call the mental health center.”
b. “I can’t drink even one or two beers.”
c. “Anxiety makes it more likely I will hear voices.”
d. “I can skip a pill when I am feeling too tired from them.”
e. “Possible bad effects from the pills only last a few days.”

Answer 62

a. “If I am having trouble sleeping or eating, I will call the mental health center.”
b. “I can’t drink even one or two beers.”
c. “Anxiety makes it more likely I will hear voices.”

In schizophrenia, the client and the family need to receive teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the health care provider’s office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client’s medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms.

Question 63

A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic?
a. “That must be frightening to you. Can you tell me how you feel about it?”
b. “There are no people living on Mars.”
c, “What do you mean when you say they’re going to invade the Earth?”
d. “I know you believe the Earth is going to be invaded, but I don’t believe that.”

Answer 63

a. “that must be frightening to you. Can you tell me how you feel about it?”

This response addresses the client’s underlying fears without feeding the delusion. Refuting the client’s delusion would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion would also reinforce the delusion. Voicing disbelief about the delusion wouldn’t help the client deal with the underlying fears.

Question 64

A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client’s extrapyramidal symptoms?
a. benztropine
b. dantrolene
c. clonazepam
d. diazepam

Answer 64

a. benztropine

Benztropine is an anticholinergic administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine, is administered to reduce anxiety.

Question 65

When caring for a client receiving haloperidol, the nurse should assess for which problem?
a. orthostasis
b. extrapyramidal symptoms
c. hypersalivation
d. oversedation

Answer 65

b. extrapyramidal symptoms

Haloperidol, a traditional antipsychotic drug, is associated with a high rate of extrapyramidal adverse effects.
At therapeutic dosages, haloperidol is associated with a low incidence of sedation and orthostasis.
Hypersalivation is an adverse effect of clozapine.

Question 66

A client with schizophrenia is responding well to risperidone and is no longer psychotic. After the nurse teaches the client about managing the illness, which statement by the client reflects a need for further intervention?

a. “I just don’t know if I can remember to keep taking medicines every day.”
b. “When my thoughts start racing, I know I need to relax more.”
c. “I can name the side effects of risperidone, but I’m not having any.”
d. “I don’t listen to my parent’s religious beliefs about not using medicines.”

Answer 66

a. “I just don’t know if I can remember to keep taking medicines every day.”

The major cause of relapse is nonadherence to the medication treatment plan. If the client is worried about remembering to take the medicines on a regular basis, it is a warning sign to the nurse that the client may be at risk for noncompliance. The nurse needs to discuss strategies to help the client establish a new routine such as using digital reminders, integrating medications into a daily routine, and utilizing family support systems when available. Understanding when to relax and the side effects of medicines are positive findings. Choosing not to listen to a family member’s negative beliefs about medication is also a positive finding.

Question 67

A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be “sacrificed to save the world.” Which action should the nurse take first?

a, Administer an oral antipsychotic.
b. Ask a family member to stay with the client.
c. Institute suicide precautions.
d. Encourage the client to describe the suicide plan.

Answer 67

c. institute suicide precautions.

Delusions of grandeur are common symptoms of the manic phase of bipolar disorder. The priority nursing action is to maintain client safety and institute suicide precautions. Administering an antipsychotic and asking about the suicide plan are acceptable nursing actions, but first the nurse must ensure client safety. Asking a family member to sit with the client inappropriately delegates responsibility to someone else; the nurse must address the issue of client safety immediately.

Question 68

The director of an outpatient rehab program tells the nurse that a client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took their place as leader of the group. Based on this information, which intervention is most appropriate?
a. Make a home visit and tell the client that if they do not return to the program, they will lose their place there.
b. Ask the director to assign the client to another group when they return to the program.
c. Make an appointment to meet the client at the mental health center, and ask them about the situation.
d. Arrange for the placement of the client in a skill-training program.

Answer 68

c. make an appointment to meet the client at the mental health center, and ask them about the situation.

The most therapeutic action at this time is for the nurse to make an appointment with the client at the mental health center to explore their feelings and behavior. Doing so acknowledges the client’s importance and makes them a partner in resolving the problem. The nurse needs to determine what is going on in the situation first and then plan accordingly. Threatening the client with loss of the position, asking for a new assignment for the client, or arranging for the placement of the client in a skill training program is inappropriate and premature.

Question 69

A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. On the way to the radiology department, the client looks around anxiously and tells the nurse, “The Interpol is coming to kill me.” What is the nurse’s best response?
a. “The Interpol isn’t here.”
b. “Your illness is causing you to hear voices.”
c. “It sounds like you’re frightened.”
d. “No one can hurt you here.”

Answer 69

c. “It sounds like you’re frightened.”

Even though the client’s thinking processes are distorted and irrational, the feelings are very real. The nurse should intervene by empathizing with the emotions. Assuring the client that the Interpol isn’t present, saying that the illness is causing the client to hear voices, and saying that no one can hurt the client appeal to the logical reasoning the client’s illness has impaired. These responses may increase the client’s anxiety by denying the reality of the current emotional experience.

Question 70

A client who’s taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect?
a. agranulocytosis
b. extrapyramidal effects
c. anticholinergic effects
d. neuroleptic malignant syndrome

Answer 70

d. neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a rare but potentially fatal effect of antipsychotic medication. This condition generally begins with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.

Question 71

A nurse is caring for a client who recently starting taking haloperidol. Which client assessment would be a priority for nurse follow up?

a. Elevated liver function tests
b. Neck stiffness with head tilt
c. Frequent day naps
d. Dry mouth with nausea

Answer 71

b. neck stiffness with head tilt

An antipsychotic agent like haloperidol can cause acute dystonic reactions such as muscle spasms in the neck, face, tongue, back, and legs, as well as torticollis. Torticollis is neck stiffness that causes the head to tilt to one side with the chin pointing in the opposite direction. This adverse reaction requires prompt follow up by the nurse as early detection of dystonic reactions can minimize complications. Elevated liver function tests, dry mouth, and nausea are common adverse reactions that require follow up; however, they are not priority. Although haloperidol is one of the least sedating antipsychotics, drowsiness and dizziness are common side effects and usually subside after a few weeks.

Question 72

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client’s nutritional needs at this time?
a. a green salad topped with chicken pieces
b. a peanut butter sandwich
c. a bowl of vegetable soup
d.favorite foods from home

Answer 72

b. a peanut butter sandwich

Giving the client finger foods that have protein, carbohydrates, and calories supplies energy and allows the client to eat while on the move. A salad or soup is very difficult for the client to eat while moving and may not supply the nutrients needed. Favorite foods from home may or may not be appropriate to eat while walking.

Question 73

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. What assessment data obtained by the nurse correlates with the client’s disorder?

a. unpredictable actions and intense interpersonal relationships
b. inability to function as a responsible parent
c. chronic extreme pain that cannot be explained by any medical condition
d, apathy, detachment, and lack of affectionate feelings

Answer 73

a. unpredictable actions and intense interpersonal relationships.

A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable, and behavior may be inappropriate and impulsive. Although the client’s impaired ability to form relationships may affect parenting skills, the inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Apathy, detachment, and lack of affectionate feelings typify schizoid and schizotypal personality disorders.

Question 74

While pacing in the hall, a client with schizophrenia runs to a nurse and asks, “Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!” How should the nurse respond during the early stage of the therapeutic process?
a. “I’m a nurse. I’m not poisoning you. That would be a violation of the nursing code of ethics.”
b. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”
c. “I’m not poisoning you. And how could I possibly steal your soul?”
d. “I sense anger. Are you feeling angry today?”

Answer 74

b. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”

The nurse should directly orient a delusional client to reality, especially to place and person. Denying poisoning and offering delusion-related information may encourage further delusions related to the delusion. Validating the client’s feelings occurs during a later stage in the therapeutic process.

Question 75

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

a. The client will be free from anxiety and be able to use self-calming techniques before reaching panic level.
b. The client will be oriented to person, place, and time.
c. The client will show no self-harm or harm to staff.
d. The client will be able to problem solve in situations on the psychiatric unit.

Answer 75

c. the client will show no self-harm or harm to staff.

The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client’s anxiety and orientation is a concern and is important for the client’s care, the client’s safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.

Question 76

A client with paranoid schizophrenia is recently admitted to the psychiatric unit. The client is hesitant to eat the food provided and states “I know they poisoned this food before putting it on my plate.” What is the priority nursing action?

a. Bring the client food in unopened containers.
b. Request a cannabinoid appetite enhance from the provider.
c, Have the family bring in the client’s favorite food.
d. Ask the client which poison is inside the food.

Answer 76

a. bring the client food in unopened containers.

Clients with paranoid schizophrenia are often concerned about the safety of their food. Bringing the client food in unopened containers may ease this paranoia. Because the client was recently admitted to the unit, requesting an appetite enhancer from the health care provider is not the priority action at this time. The nurse should attempt other strategies first. Having the family bring in food is passing the buck. The nurse should seek out strategies to help this client situation. Asking the client which poison is in the food is exploring the paranoia, which is not an appropriate nursing action.

Question 77

A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?
a. restlessness, difficulty sitting still, and pacing
b. involuntary rolling of the eyes
c. tremors, shuffling gait, and masklike face
d. extremity and neck spasms, facial grimacing, and jerky movements

Answer 77

c. tremors, shuffling gait, and masklike face.

Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and “pill rolling.” Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis characterized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered a medical emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

Question 78

A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse’s teaching about this medication?
a. “I need to call my health care provider in 2 weeks for a checkup.”
b. “I need to keep my appointment here at the clinic this week for a blood test.”
c. “I can drink alcohol with this medication.”
d. “I can take over-the-counter sleeping medication if I have trouble sleeping.”

Answer 78

b. “I need to keep my appointment here at the clinic this week for a blood test.”

Mandatory weekly white blood cell counts are used to detect developing agranulocytosis, which can be fatal and occurs in 1% to 2% of clients taking clozapine. This medication is associated with a risk for seizures; this risk is dose-dependent, meaning that it increases with moderate to high doses (600 to 900 mg/day).
While the need to call the health care provider in 2 weeks may be true, it does not reflect an understanding of the medication.
The use of alcohol or over-the-counter sleeping medications is contraindicated.