exam 3 Flashcards
Which drug should the nurse be prepared to admin to a client with a hx of opiate overdose
Naloxone
After assessing a victim of sexual assault which terms could the nurse use in documentation
alleged
reported
refused
penetration
What information should not be obtained during initial medial exam of a sexual assault victim
Ascertaining what she might have done to provoke this situation
During a counseling session the client cannot directly answer questions eventually making their point the nurse identifies this as
Circumstantial speech
An older client is experiencing decreased sensory capabilities and difficulty communicating. What interventions are appropriate to improve communication during the physical assessment
Looks directly at client when speaking
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
Vocational rehab
Psychoeducation classes
Social skills training
Which distinguishing criterion is present in Somatic symptom disorder but absent in anxiety disorder
They experienced significant physical symptoms
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
Wise business decisions
A nurse assesses five newly hospitalized pts. Which pts have the highest suicide risk
17 year old white female adolescent
82yo white man
22yo man with TBI
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
Assess the client for self harm
Which type of therapy encourages story telling and seniors in socialization and improve mood
Reminisce
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
DNA swabs
Body map
Camera
Which intervention will the nurse implement to deescalate a client who is aggressive and displaying signs of potential violence
Be assertive not aggressive
Give clear simple direction
Identify stressors and stress indicators
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
Scapegoating
The nurse is planning activities for clients dx with bipolar disorder with aggressive social behavior. Which activity will be most appropriate
sweep the floor
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
Hallucinations
Members at a local church are meeting with poor homeless family whom they are supporting. Which member statement is an example of altruism
I can give you the baby clothes i no longer need
What is the most appropriate nursing action to help manage manic clients who are monopolizing a group therapy session
Thank the client for their input but inform the client that others need a chance to contribute
A pt taking lithium should have which instruction included in his or her tx
Maintain normal salt and fluid in the diet
After a pt dies his hospice nurse finds that she feels devastated by the loss. Which type of grief is she experiencing
Disenfranchised grief
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
Shame and humiliation
Self imposed isolation
recent stressful life event
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
Withdrawal seizure
Which economic factors most critical to the success of discharge planning for a pt dx with severe and persistent mental illness
Access to housing
Availability of health insurance
Income to meet basic needs
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
Hx of alcohol abuse
Which nursing dx is most appropriate for a client admitted for overdose of their antidepressants
Risk for suicide
A client who is experiencing disturbed thoughts
use open ended questions and silence
Which questions would be a priority when assessing for symptoms of major depression
You look very sad have you had thoughts of harming yourself
A nurse instructs a pt taking a drug that inhibits the alcohol of MAO to avoid tyramine containing foods because of the risk of
HTN crisis
When considering ethical issues
the code of ethics for nurses with interpretive statements
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
Hypomania
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
Humanism
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
anhedonia
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
penetration without consent
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
Aphasia
Which information should the nurse include in health teaching for adults diagnosed with
ADHD and their significant others? SATA
Cognitive therapy may help resolve internalized negative beliefs
Tendency for genetic transmission
Prevention strategies related to substance abuse
Treatment for a patient that is experiencing a heroin overdose should begin with
Aspirate secretion
Which of the following clients will the nurse not anticipate the need for electroconvulsive
shock therapy ECTP
Bipolar pt with cochlear implant
Acute onset of disordered thinking is most associated with
Delirium
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
melatonin
A patient was started on (escitalopram)Lexapro 5 days ago and now says “ this medicine isn’t working
Explain the time lag before antidepressants relieve symptoms
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 ?
Application of a transcutaneous electrical nerve stimulation unit
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
Set limits and consistently reinforce
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
Runny nose, yawning, insomnia, and chills
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
Separate and distract the patients. Take one to the day room and the other to an activities area.
A client experiencing alcochol withdrawal delirium would have which of the following
symptoms? SATA
- Tachycardia
- Delusions
- Tactile Hallucinations
- Diaphoresis
individuals with serious mental illness are likely to experience which of the following? SATA
- Unemployment
- Homelessness
- Substance abuse
- Lack of medical care
Indicators for improvement of a client that was sexually assaulted would include the
following? SATA
- Relief of anger in non destructive ways
- Feelings of empowerment and expressions of hope
- Evidence of comfort in relationships
