Ex Questions

Question 1

The hospice nurse is visiting a dying client. Talking about belongings when client dies. Ask out of the clients room. Why?

Answer 1

Although near death, the client can probably hear the convo

Question 2

New nurse and caring for end of life pt. Health response to dying patient and family

Answer 2

Paying close attention to details regarding pain and comfort measures

Question 3

During a home health care visit an older adult patient states to the nurse that his wife died 3 years ago. Which is an indication of complicated grief

Answer 3

Keeping her room the exact way it was when she died

Question 4

Patient with bipolar disorder may be 4 weeks pregnant

Answer 4

Confer w physician and stop lithium meds

Question 5

Patient experiencing manic episode and states I hate oatmeal…. I’m burning up. Which is a priority nursing actions

Answer 5

Take temp and pulse

Question 6

Obstructive sleep apnea, being discharged and needs further teaching after which statement

Answer 6

Glass of wine at night will help relax the airways

Question 7

Which statement indicates to the nurse additional education is needed regarding appropriate sleep hygiene

Answer 7

Exercising before bed will make me tired

Question 8

I take herbal products to help me sleep, nursing response

Answer 8

Uncontrolled products, and variation of dosages

Question 9

Which statement made indicates insomnia

Answer 9

I go to sleep okay but wake up several times at night

Question 10

Teenager admitted with adjustment disorder and depression. Highest priority when planning patients care

Answer 10

Finds no pleasure in living (anhedonia) (dysthymia: mild depression chronic)

Question 11

Nurse administers ssri to suicidal patient. Medication addresses

Answer 11

Irregularities in serotonin system

Question 12

Family member asks nurse about suicidal patient. Any med that can prevent commitment of suicide

Answer 12

Antidepressants treat mood disorders that accompany suicidal ideation

Question 13

A nurse working at a crisis center received a call from a patient that he was depressed and wanted to die. Has items, which is most concerning

Answer 13

A loaded gun

Question 14

Day 4 after suicidal attempt, patient says you dont have to worry about them any more and you can stop suicidal precautions

Answer 14

Reporting the patients statements and suggest increased vigilance

Question 15

What information concerning amytryptilline at 50 mg TID. What would the nurse tell the patient about the therapeutic effects of med

Answer 15

Med is expected to improve brain chem imbalance

Question 16

A patient is displaying escalating thoughts of suicide with a plan. Which action reflects this

Answer 16

Shallow cuts on arm with butter knife all the way from wrist to elbow

Question 17

Not support diagnosis of narcolepsy

Answer 17

Sleep study reports excessive loud snoring

Question 18

A highly agitated client paces the unit and states I could buy and sell this place. The clients mood fluctuates from fits of laughter to anger. Which is most accurate documentation of the clients behavior

Answer 18

Agitated and pacing, exhibiting grandiosity, mood labile

Question 19

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

Answer 19

D. Symptoms indicate lithium carbonate toxicity

Question 20

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

Answer 20

C. The client will remain safe throughout the hospitalization.

Question 21

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom

Answer 21

B. “I’m the world’s most perceptive attorney.”

Question 22

A client on an inpatient unit is diagnosed with bipolar disorder: manic phase. During a discussion in the dayroom about weekend activities, the client raises voice, becomes irritable, and insists that plans change. What should be the nurse’s initial intervention?
C

Answer 22

C. Assist the client to move to a calmer location.

Question 23

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?

Answer 23

2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

Question 24

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?
1

Answer 24

1. Risk for suicide R/T hopelessness

Question 25

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe?

Answer 25

2. Valproic acid (Depakote)

Question 26

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing response?

Answer 26

4. “Zyprexa calms hyperactivity until the Eskalith takes effect.”

Question 27

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?

Answer 27

3. “Weight gain is a common, but troubling, side effect.”

Question 28

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

Answer 28

4. Symptoms indicate lithium carbonate toxicity.

Question 29

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?

Answer 29

2. “FIND” tool
Rationale: The nurse should use the “FIND” tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

Question 30

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

Answer 30

4. “Treatment is compromised when clients choose not to take their medications.”

Question 31

A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week

Answer 31

1. Provide client with high-calorie finger foods throughout the day.

Question 32

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes?

Client Outcomes:

1. Maintains nutritional status.

2. Interacts appropriately with peers.

3. Remains free from injury.

4. Sleeps 6 to 8 hours a night.

Answer 32

C. 3, 1, 4, 2

Question 33

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders?

Answer 33

B. Valproic acid (Depakote)

Question 34

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?

Answer 34

B. This disorder is more prevalent in the higher socioeconomic groups.

Question 35

An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order?

Answer 35

This dosage is more than twice the recommended dosage range.

Question 36

A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation?

Answer 36

A. To provide self and client with a safe environment

Question 37

A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess?

Answer 37

B. The client has endured periods of elation and dysphoria lasting for more than 2 years

Question 38

After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement

Answer 38

Ill call my doctor immediately if I experience any diarrhea or ringing in my ears.

Question 39

A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level?

Answer 39

B. 1.7 mEq/L

Question 40

A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client?

Answer 40

C. Risk for violence: directed toward others R/T agitation and hyperactivity

Question 41

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

Answer 41

B. I will maintain normal salt intake.

Question 42

A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action?

Answer 42

Assess the clients vital signs

Question 43

A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess?

Answer 43

Flight of ideas

Question 44

The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom dcor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate?

Answer 44

D. Rooms should be painted with neutral colors and contain pale-colored accessories.

Question 45

A clients spouse asks, What evidence supports the possibility of genetic transmission of bipolar disorder? Which is the best nursing reply?
B

Answer 45

B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder.

Question 46

client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client?
A

Answer 46

A. Using a calm, unemotional approach during client interactions

Question 47

Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? Select all that apply.

Answer 47

A. Avoid excessive use of beverages containing caffeine.
B. Maintain a consistent sodium intake.
C. Consume at least 2,500 to 3,000 mL of fluid per day.

Question 48

Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply.

Answer 48

A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms.

B. Children are naturally active, energetic, and spontaneous