exam 3

Question 1

Which drug should the nurse be prepared to admin to a client with a hx of opiate overdose

Answer 1

Naloxone

Question 2

After assessing a victim of sexual assault which terms could the nurse use in documentation

Answer 2

alleged
reported
refused
penetration

Question 3

What information should not be obtained during initial medial exam of a sexual assault victim

Answer 3

Ascertaining what she might have done to provoke this situation

Question 4

During a counseling session the client cannot directly answer questions eventually making their point the nurse identifies this as

Answer 4

Circumstantial speech

Question 5

An older client is experiencing decreased sensory capabilities and difficulty communicating. What interventions are appropriate to improve communication during the physical assessment

Answer 5

Looks directly at client when speaking

Question 6

An adult pt tells the case manager “I dont have bipolar anymore so I don’t need medicine. After I was in the hospital last year you helped me get an apartment and disability checks. Now i’m bored and don’t have any friends. Which resources should the nurse suggest for this pt

Answer 6

Vocational rehab
Psychoeducation classes
Social skills training

Question 7

Which distinguishing criterion is present in Somatic symptom disorder but absent in anxiety disorder

Answer 7

They experienced significant physical symptoms

Question 8

The nurse is completing the admission assessment and hx for a client admitted to the behavioral care unit. Which characteristic is not consistent with manic episodes of a pt with bipolar one

Answer 8

Wise business decisions

Question 9

A nurse assesses five newly hospitalized pts. Which pts have the highest suicide risk

Answer 9

17 year old white female adolescent
82yo white man
22yo man with TBI

Question 10

The nurse is caring for a client in the ED whose labs and tests are negative. The client becomes agitated demanding to be admitted. The nurse suspects self directed factitious disorder. Which nursing action is a priority in the delivery of care

Answer 10

Assess the client for self harm

Question 11

Which type of therapy encourages story telling and seniors in socialization and improve mood

Answer 11

Reminisce

Question 12

A forensic nurse is preparing to collect evidence from a client who was sexually assaulted. Which supplies will the nurse anticipate to be used to collect forensic evidence

Answer 12

DNA swabs
Body map
Camera

Question 13

Which intervention will the nurse implement to deescalate a client who is aggressive and displaying signs of potential violence

Answer 13

Be assertive not aggressive
Give clear simple direction
Identify stressors and stress indicators

Question 14

During a family therapy session the teen points to her siblings and states “It’s his fault not mine you only pay attention to him.” The client is demonstrating which of the following

Answer 14

Scapegoating

Question 15

The nurse is planning activities for clients dx with bipolar disorder with aggressive social behavior. Which activity will be most appropriate

Answer 15

sweep the floor

Question 16

The nurse is assigned the care of four clients who are detoxing from alcohol. The pt with which symptom would be the nurses highest priority

Answer 16

Hallucinations

Question 17

Members at a local church are meeting with poor homeless family whom they are supporting. Which member statement is an example of altruism

Answer 17

I can give you the baby clothes i no longer need

Question 18

What is the most appropriate nursing action to help manage manic clients who are monopolizing a group therapy session

Answer 18

Thank the client for their input but inform the client that others need a chance to contribute

Question 19

A pt taking lithium should have which instruction included in his or her tx

Answer 19

Maintain normal salt and fluid in the diet

Question 20

After a pt dies his hospice nurse finds that she feels devastated by the loss. Which type of grief is she experiencing

Answer 20

Disenfranchised grief

Question 21

A college student failed two exams. The student cried for hours and then tried to call parents but got no answer. The student then suspended access to his social media. Which suicide risk factor is present

Answer 21

Shame and humiliation
Self imposed isolation
recent stressful life event

Question 22

The nurse is caring for a client admitted to an inpatient chemical dependency program for alcohol abuse. Which action is a priority assessment within 12-24hrs of admission

Answer 22

Withdrawal seizure

Question 23

Which economic factors most critical to the success of discharge planning for a pt dx with severe and persistent mental illness

Answer 23

Access to housing
Availability of health insurance
Income to meet basic needs

Question 24

The nurse is admitting a pt dx with bipolar one. When assessing the client’s suicide risk, Which of the following will the nurse identify as imposing greatest risk

Answer 24

Hx of alcohol abuse

Question 25

Which nursing dx is most appropriate for a client admitted for overdose of their antidepressants

Answer 25

Risk for suicide

Question 26

A client who is experiencing disturbed thoughts

Answer 26

use open ended questions and silence

Question 27

Which questions would be a priority when assessing for symptoms of major depression

Answer 27

You look very sad have you had thoughts of harming yourself

Question 28

A nurse instructs a pt taking a drug that inhibits the alcohol of MAO to avoid tyramine containing foods because of the risk of

Answer 28

HTN crisis

Question 29

When considering ethical issues

Answer 29

the code of ethics for nurses with interpretive statements

Question 30

A client admitted to the mental health unit runs into the day room and yells “I am superman I can fly” What behaviors does the nurse recognize this as being related to

Answer 30

Hypomania

Question 31

The nurse is holding a group session on grief for those who have experienced loss. During the meeting the nurse actively listens and utilizes socratic inquiry to promote self actualization and awareness. The nurse is using which theoretical premises

Answer 31

Humanism

Question 32

A pts parents have described their son lacks interest in things he used to enjoy like games with his friends and classes. This may be described by the term

Answer 32

anhedonia

Question 33

The nurse is caring for a female client in the ED after being sexually assaulted. Upon completing the admission interview the nurse understands the difference between completed rape and attempted rape is

Answer 33

penetration without consent

Question 34

The nurse observes that during communication with a client they become increasingly anxious and are unable to find the correct words. Which term used to describe what the client is experiencing

Answer 34

Aphasia

Question 35

Which information should the nurse include in health teaching for adults diagnosed with
ADHD and their significant others? SATA

Answer 35

Cognitive therapy may help resolve internalized negative beliefs
Tendency for genetic transmission
Prevention strategies related to substance abuse

Question 36

Treatment for a patient that is experiencing a heroin overdose should begin with

Answer 36

Aspirate secretion

Question 37

Which of the following clients will the nurse not anticipate the need for electroconvulsive
shock therapy ECTP

Answer 37

Bipolar pt with cochlear implant

Question 38

Acute onset of disordered thinking is most associated with

Answer 38

Delirium

Question 39

The nurse is teaching a client about the use of light therapy in the treatment of seasonal
affective disorder depression. The nurse explains that light therapy has been found to
suppress which of the following

Answer 39

melatonin

Question 40

A patient was started on (escitalopram)Lexapro 5 days ago and now says “ this medicine isn’t working

Answer 40

Explain the time lag before antidepressants relieve symptoms

Question 41

An elderly client with a history of dementia is complaining of back pain. Which of the following is least likely to cause an adverse reaction ?

Answer 41

Application of a transcutaneous electrical nerve stimulation unit

Question 42

The nurse is caring for a client in a hyperactive state who is pacing and easily distracted.Which is appropriate for the nurse to implement

Answer 42

Set limits and consistently reinforce

Question 43

A newly hospitalized patient has needle track on both arms. A friend states that the patient
uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for

Answer 43

Runny nose, yawning, insomnia, and chills

Question 44

Two patients in a residential facility are diagnosed with dementia. One shouts to the other.
“Move along, you’re blocking the road”. The other patient shouts back

Answer 44

Separate and distract the patients. Take one to the day room and the other to an activities area.

Question 45

A client experiencing alcochol withdrawal delirium would have which of the following
symptoms? SATA

Answer 45

• Tachycardia
• Delusions
• Tactile Hallucinations
• Diaphoresis

Question 46

individuals with serious mental illness are likely to experience which of the following? SATA

Answer 46

• Unemployment
• Homelessness
• Substance abuse
• Lack of medical care

Question 47

Indicators for improvement of a client that was sexually assaulted would include the
following? SATA

Answer 47

• Relief of anger in non destructive ways
• Feelings of empowerment and expressions of hope
• Evidence of comfort in relationships