Finals Exam Notes Flashcards
An older client is admitted to a psychiatric hospital with the diagnosis, “Major depression, single episode.” Which laboratory value is most important for the nurse to report to the healthcare provider immediately?
Increased thyroid stimulating hormone (TSH).
A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the organ donor is no longer available, the client slams the doors and shouts vulgarities about his situation. Which action should the nurse implement?
Express concern over his disappointment.
During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, “I look around to see who’s talking to me, and I can’t see anybody.” Another client replies, “I used to hear voices, too. I found out they were my imagination. The voices you hear aren’t real either.” Which phenomenon, common to groups, is exemplified in this interchange?
Reality testing.
Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client?
Self-analysis.
A client is told that her infant will be stillborn. Which is the most important action for the nurse to implement after the birth?
Ask the family if they would like to see and hold the infant after birth.
Which action should the nurse implement first for a client experiencing alcohol withdrawal?
Prepare environment to prevent self-injury.
The nurse is planning the care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client’s plan of care?
Search the client’s personal belongings.
The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider?
Global confusion and inability to recognize family members.
The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, “Self-esteem, chronic low.” Which client response indicates to the nurse that the client has improved self-esteem?
Identifies own strengths.
A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client’s family leaves, the client tells the nurse, “I signed the papers because my husband told me I will be deported if my depression is not cured.” What information should the nurse report to the healthcare provider?
The client’s consent may have been coerced.
The daughter of an older male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function?
Cannot mentally retrace objects that were recently misplaced.
Which client outcome during hospitalization indicates an improvement for a client who is admitted with auditory hallucinations?
Argues with the voices.
Tells when voices decrease.
Follows what the voices say.
Tells the nurse what the voices say.
Tells when voices decrease.
A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, “Don’t touch me! You’re so stupid that you’ll make it worse!” Which intervention is best for the nurse to implement?
Provide information about infection prevention.
The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96 mmHg. Which is the priority nursing action?
Encourage the client to stop pacing and sit down.
Reevaluate the client’s blood pressure in an hour.
Direct the client to attend recreational therapy.
Review the client’s baseline blood pressure.
Reevaluate the client’s blood pressure in an hour.
A female client presents to the emergency center with confusion and emotional numbness and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. Which action should the nurse implement first?
Explain the rape protocol to the client.
A client who abuses alcohol says to the nurse, “I am glad I went in for treatment. Now my problems with alcohol are all behind me.” Which response is best for the nurse to provide?
Tell me more about what you mean when you say that your problems with alcohol are now behind you.
When assessing a client’s emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness?
Interpersonal and intrapersonal skills.
Which action should the nurse implement during the termination phase of the nurse-client relationship?
Help summarize accomplishments.
The daughter of a female client with stage-1 Alzheimer’s disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. Which finding should the nurse tell the daughter is common?
Inability to recognize one’s location.
Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby?
Keep the body available for a few hours in case they change their minds.
What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable?
Reflect client’s behavior and consequences.
Which client should the nurse identify as the highest risk for the onset of stress-related problems?
A person whose father died three months ago, who is losing a job due to company downsizing, and states, “Living with loss and the threat of loss makes me feel helpless.”
An adult female who is married and works full-time in a factory has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question should the nurse use?
How did this happen to you?
A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain?
Drugs taken in last 7 days.
Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?
Establish rapport in each phase of the nurse-client relationship.
Determine the client’s ability to communicate effectively.
Reflect on previous psychiatric interviews the nurse has performed.
Ensure data is collected and recorded in a systematic sequence.
Establish rapport in each phase of the nurse-client relationship.
Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care?
If I fail another class, I’m going to kill myself.
I have a necktie in my room that I can use to hang myself.
When I leave home to live on my own, I’m buying myself a gun.
I took two bottles of Mom’s pills and had to have my stomach pumped.
I have a necktie in my room that I can use to hang myself.
A nurse is teaching about women’s health with a female client who is in a homosexual relationship. Which topic is the most important for the nurse to address?
Sexually transmitted diseases.
Annual gynecologic examination.
Monthly breast self-examination.
Domestic violence interventions.
Domestic violence interventions.
The client with depression asks the nurse, “ What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain.” What information should the nurse use to support an explanation of neurotransmitters?
Chemical messengers that cause brain cells to turn on or off.
Areas of the brain that are responsible for controlling emotions.
Clumps of cells that alert the other brain cells to receive messages.
Web-like structures that provide connections among parts of the brain.
Chemical messengers that cause brain cells to turn on or off.
A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?
Images indicate the presence of tumors and scars.
The scan clearly outlined structures of the brain.
Results show activity in various portions of the brain.
PET shows biochemical levels of neurotransmitters.
Results show activity in various portions of the brain.
The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include in the plan of care?
Emphasize the client’s strengths and assets.
Teach the importance of medication compliance.
Offer the client psychoeducational materials to read.
Focus on the client’s positive or negative feelings toward the nurse.
Focus on the client’s positive or negative feelings toward the nurse.
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem?
Impaired mobility.
Ineffective individual coping.
Impaired verbal communication.
High risk for fluid and electrolyte imbalance.
High risk for fluid and electrolyte imbalance.
The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client?
Coping skills.
Physical exercise.
Grief management.
Social support.
Coping skills.
Which client statement should the nurse identify as most typical of a client with mania?
I can’t do anything anymore.
I can’t understand where all our money goes.
I manage our finances great because I buy in big quantities.
I wonder why my wife is so upset that I spend money easily.
I manage our finances great because I buy in big quantities.
Which action should the nurse implement during the termination phase of the nurse-client relationship?
Identify new problem areas.
Confront changes not completed.
Explore the client’s past in depth.
Help summarize accomplishments.
Help summarize accomplishments.
A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time?
Check on the client every 15 minutes.
Begin one-on-one supervision immediately.
Keep the room dimly lit and turn on the radio.
Push fluids and provide calorie-rich nutritional supplements.
Begin one-on-one supervision immediately.
