PROC retake

Question 1

A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first?
a. Place the child in seclusion
b. Use therapeutic hold technique
c. Apply wrist restraints
d. Administer risperidone

Answer 1

a. Place the child in seclusion

Question 2

A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?

a. Dependent
b. Paranoid
c. Borderline
d. Histrionic

Answer 2

a. Dependent

Question 3

A nurse is caring for a client who is in- voluntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the fol- lowing actions should the nurse take?

a. Inform the client that he does not have the right to refuse medication
b. Administer the medication to the client via IM injection
c. Offer the client the medication at the next scheduled dose time
d. Implement consequences until the client take the medication

Answer 3

c. Offer the client the medication at the next scheduled dose time

Question 4

A nurse is caring for a client in the emergency department who states she was beaten and sexually assault by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

a. Conduct a pregnancy test
b. Requests mental health consultation for the client
c. Provide a trained advocate to stay with the
prophylactic medication client.
d. offer prophylactic medication to prevent STIs

Answer 4

d. offer prophylactic medication to prevent STIs

Question 5

A nurse is caring for a client who re- ports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the fol- lowing defense mechanisms is the client demonstrating?
a. Rationalization
b. Denial
c. Compensation
d. Displacement

Answer 5

d. Displacement

Question 6

A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?

a. Request that the client’s partner sign the consent
form
b. Cancel the schedule ECT procedure
c. Proceed with the preparation for ECT based on implied consent
d. Inform the client about the risks of refusing the ECT

Answer 6

b. Cancel the schedule ECT procedure

Question 7

A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
a. The child is 10years old
b. The child is homeschooled
c. The has no siblings
d. The child has cystic fibrosis

Answer 7

d. The child has cystic fibrosis

Question 8

A nursing is advising an assistive per- sonnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?

a. Please don’t take what the client said seriously when she is
depressed
b. It’s important that the client feel safe verbalizing how she is feeling
c. Everybody feels that way about this client so don’t worry about it
d. I’ll change your assignment to some- one who doesn’t have depressive disorder

Answer 8

b. It’s important that the client feel safe verbalizing how she is feeling

Question 9

A nurse Is providing behavioral therapy for a client who has obsessive compulsive disorder.The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

a. Keep a journal of how often you check the locks each night
b. Snap a rubber band on your wrist when you think about checking the locks
c. Ask a family member to check the lock for you at night
d. Focus on abdominal breathing when- ever you go to check the locks

Answer 9

b. Snap a rubber band on your wrist when you think about checking the locks

Question 10

A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam

a. Bradycardia
b. Stupor
c. Afebrile
d. Hypertension

Answer 10

d. Hypertension

Question 11

A nurse is creating a plan of care of a client who has anorexia nervosa.Which of the following intervention should the nurse include in the plan?

a. Weigh the client twice per day
b. Prepare the client for electroconvulsive therapy
c. Set a weight gain goal of 2.2kg (5lbs) per week
d. Encourage the client to participate in family therapy

Answer 11

d. Encourage the client to participate in family therapy

Question 12

A nurse is planning care for a 3-year-old child who has autism spec- trum disorder. Which of the following find- ing should the nurse expect?

a. Readily initiates conversation
b. Enjoys imaginative play
c. Strong relationship with sibling and peers
d. Attachment to objects that spin

Answer 12

d. Attachment to objects that spin

Question 13

A nurse is planning care for a client who has bipolar disorder. The client re- ports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.

a. Secure the client’s valuable possessions
b. Limit loud noises in the client’s environment
c. Encourage the client to participate in structured solitary activities
d. Provide high calorie snacks to the client

Answer 13

b. Limit loud noises in the client’s environment

Question 14

A nurse is evaluating the medica- tion response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication.
a. Blocks aldehyde dehydrogenase
b. Prevents the anxiety of abstinence
c. Reduce substance craving
d. Decreases the likelihood of seizures

Answer 14

c. Reduce substance craving

Question 15

A nurse in an alcohol treatment facility is caring for a client who states “my job is so stressful that the
only way I can come it is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms?

a. Repression
b. Rationalization
c. Introjection
d. Intellectualization

Answer 15

b. Rationalization

Question 16

A nurse is caringf or a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?

a. How does this situation affect your life? b. Do you see your current situation affecting your
future?
c. Can you describe how you are currently feeling?

Answer 16

c. Can you describe how you are currently feeling?

Question 16

A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with class- mates. Which of the following interven- tion is the nurse’s priority at this time?

a. Contact the adolescent’s parents
b. Suggest the adolescent join support groups
c. Ask the adolescent if he is considering hurting himself
d. Determine when the adolescent’s change in behavior began

Answer 16

d. Determine when the adolescent’s change in behavior began

Question 17

A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?

a. Slurred speech
b. Hypotension
c. Bradycardia
d. Hyperthermia

Answer 17

a. Slurred speech

Question 18

A nurse is assessing a client who has histrionic personality disorder. Which of the following finds should the nurse expect?

a. Lack of remorse
b. Attention seeking
c. Splitting of staff
d. Identity disturbance

Answer 18

b. Attention seeking

Question 19

A nurse is providing teaching to the daughter of an older client who has OCD. Which of the following statements by the daughter indicates an understanding of the disorder?

a. I will limit my mothers clothing choices when she is getting dressed
b. I will provide my mother with detailed instructions about how to perform self-care
c. I will wake my mother up a couple of times in the night to check on her
d. I will discourage my mother from talk- ing about physical complaints

Answer 19

a. I will limit my mothers clothing choices when she is getting dressed

Question 20

A nurse in a mental health facility
is caring for a client who has borderline personality disorder. Which of the follow- ing should the nurse expect?

a. Self-mutation
b. Pacing back and forth
c. Preoccupation with details d. Disorga- nized speech

Answer 20

a. Self-mutation

Question 21

A nurse is reviewing the lab results on adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

a. Blood glucose 100 mg/dL
b. T4 11 mcg/dL
c. Potassium 3.7
mEq/L
d. Hgb 10 g/dL

Answer 21

d. Hgb 10 g/dL

Question 22

A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?

a. This medication is given to help with extrapyramidal side effects
b. This medication is given to help with your depression
c. Benztropine helps alleviate your hallucinations
d. Benztropine is used to counteract your tachycardia

Answer 22

a. This medication is given to help with extrapyramidal side effects

Question 23

A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?

a. Reinforce the clients orientation with the calendar
b. Refute the clients perception of visual hallucinations
c. Teach the client assertive techniques
d. Assigned the client to a different care- giver each shift

Answer 23

a. Reinforce the clients orientation with the calendar

Question 24

A nurse is creating a plan of care for a client- who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

a. Discouraged client from expressing feelings of anger
b. Identify and schedule alternative group activities for the
client
c. Encourage physical activity for the client during the day
d. Keep a bright light on in the clients room at night

Answer 24

c. Encourage physical activity for the client during the day

Question 25

A nurse is caring for a client who has PTSD r/t military service. Which of the following actions should the nurse take?

a. Encourage the client to suppress feel- ings of trauma
b. Assign the same staff to care for the client each day
c. Address the client in an authoritative manner
d. Limit the amount of time spent with the client

Answer 25

b. Assign the same staff to care for the client each day

Question 26

A nurse is providing teaching for school age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching?

a. I will provide a low sodium diet for my son
b. I will make sure my son takes the last dose of the day by 4 PM
c. I should expect my son to develop hand tremors
d. I should contact my doctor if my son urinates excessively

Answer 26

c. I should expect my son to develop hand tremors

Question 27

A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?

a. Withhold the next does of lithium
b. Repeat the lithium level test
c. Administer the next does of lithium
d. Recommended a low sodium diet

Answer 27

c. Administer the next does of lithium

Question 28

A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage par- ticipation in cognitive behavioral family therapy in response to which of the fol- lowing client statements.

a. I want to learn how to change the way I react to problems within my family
b. I want to understand why my past ex- periences are affecting my family rela- tionships
c. I want to improve my family’s under- standing of each other’s boundaries
d. I want each of my family members to be more aware of each other’s feelings

Answer 28

d. I want each of my family members to be more aware of each other’s feelings

Question 29

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wonders at night and has a history of previous falls. Which of the fund instructions should nurse including in the teaching? SATA

a. position the mattress on the floor
b. Install sensor devices on outside doors
c. Encourage physical activity prior to bedtime
d. put locks at top of doors

Answer 29

a. position the mattress on the floor
b. Install sensor devices on outside doors
d. put locks at top of doors

Question 30

A nurse is reviewing laboratory values for a client who has bipolar DO and prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity?

a. Calcium 9.0 mg/dL
b. sodium 130
mEq/L
c. chloride 98 mEq/L
d. potassium 5.0 mEq/L

Answer 30

b. sodium 130
mEq/L

Question 31

A nurse is assisting with obtaining informed- consent from client who has been declared legally incompetent. Which of the following actions should the nurse take?

a. Contact the facility social worker to obtain the consent
b. Explain implied consent to the clients family
c. Request that the clients Guardian
signed the consent
d. Ask the charge nurse to obtain an informed consent

Answer 31

c. Request that the clients Guardian
signed the consent

Question 32

A nurse is giving a presentation about intimate partner abuse for community group. Which of the following statements by a group member indicated understanding of teaching?

a. Survivors of abuse often feel guilty
b. abusers often have high self-esteem
c. the honeymoon stage of violence usually gets longer over time
d. as abuse continues, victims become more determined to be independent

Answer 32

a. Survivors of abuse often feel guilty

Question 33

A nurse is planing care for a client who has experienced intimate partner abuse. the Nurse should identify which of the following outcomes as the priority?

a. The client joins a support group
b. the client identifies techniques to re- duce her stress
c. The client develops a safety plan
d. The client identify support systems

Answer 33

c. The client develops a safety plan

Question 34

A nurse is developing a behavioral contract with the client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

a. Use projection during group therapy b.increase self-esteem
c.use bargaining skills for behavioral consequences
d. decrease the number of verbal outbursts

Answer 34

d. decrease the number of verbal outbursts

Question 35

A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?

a. Nausea
b. Random blood glucose 130 mg/dL
c. Heart rate 104 per
minute
d. sore throat

Answer 35

d. sore throat

Question 36

A nurse is counseling and adult client whose parent just died. The client states, “My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should inform the client that the preschool age child commonly has which of the following concepts of death?

a. Death is not permanent and the loved one may come back to life
b. Death is contagious and can cause other people he loves to die
c. Death creates an interest in the physical aspects of dying
d. Death is a part of life that eventually happens to everyone

Answer 36

a. Death is not permanent and the loved one may come back to life

Question 37

A nurse is reviewing the medical records for-
clients. Which of the following findings should the nurse identified as a risk factor for violent behavior?

a. Schizoid personality disorder
b. Alcohol intoxication
c. Dysthymic disorder
d. long-term isolation

Answer 37

b. Alcohol intoxication

Question 38

A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The parent of he child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?

a. Request that the parent leaves the room while you interview the child
b. Report suspected abuse to child pro- tective services
c. Ask the child how the injury occurred
d. Determine the immediate safety needs of the child

Answer 38

d. Determine the immediate safety needs of the child

Question 39

A nurse in a mental health facility is caring for a client. Which of the following actions the nurse take during though working phase of the nurse-client relationship?

a. Summarize goals and objectives
b. Address confidentiality
c. promote problem-solving skills
d. establish a participation contract

Answer 39

c. promote problem-solving skills

Question 40

a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head and says, “please forgive me, I’m not sure what came over me I don’t know why said those things.” The nurse interprets this behavior as which of the following?

a. Emotional lability
b. Confabulation
c. flight of ideas
d. Neologism

Answer 40

a. Emotional lability

Question 41

Valproic Acid expected outcome:

Answer 41

Decreased euphoric mood

Question 42

ECT

Answer 42

confusion after a few hours of treatment

Question 43

A nurse in the emergency depart- ment is assessing a client who has major depressive disorder. Which of the follow- ing actions should the nurse take? (Ex- hibit question)

a. ask the client if she has eaten foods containing thyramine
b. Give regular insulin subcutaneously to the client
c. Prepare the client for electroconvul- sive therapy
d. administer dantrolene IV bolus to the client

Answer 43

a. ask the client if she has eaten foods containing thyramine

Question 44

Carbamazepine for bipolar DO. Results report to the provider?

Answer 44

Platelets 90,000/mm3

Question 45

A nurse is caring for a client who has schizophrenia and started taking clozapine two months ago. Which
of the following laboratory results should the nurse report to the provider?

a. WBC 3,000/mm3
b. Potassium 4.2 mEq/L
c. Hgb 16 g/dL
d. Platelets 300,000/mm3

Answer 45

a. WBC 3,000/mm3

Question 46

bupropion for smoking cessation. Contraindication?

Answer 46

Seizures

Question 47

Alzheimer’s disease action by the nurse

Answer 47

use symbols to assist the client in locating rooms

Question 48

Schizophrenia. AE for thioridazine

Answer 48

Waxy flexibility

Question 49

PRIORITY finding for schizophrenia who is taking HALOPERIDOL.

Answer 49

High fever

Question 50

A nurse is leading grief support group for bereaved clients. Which of the following client statements should the nurse report to he provider as an indication of clinical depression?

a. “I don’t know how I could cope if I didn’t have my family’s support”
b. “It’ll be a long time before I’m happy again”
c. “I don’t feel anything but numbness anymore”
d. “I feel like I’m angry at the whole world right now”

Answer 50

c. “I don’t feel anything but numbness

Question 51

A nurse is teaching the parent of a school age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching?

a. Expect the child to gain weight while taking this medication
b. Crush the medication and mix it with 120 mL (4 oz) of juice
c. Therapeutic effects will occur within 24 hr of starting treatment
d. Administer the medication before the child goes to school in the morning

Answer 51

d. Administer the medication before the child goes to school in the morning

Question 52

A nurse is caring for a client who had bipolar DO and experiencing a manic episode. Which of the following actions should the nurse take?

a. Place the client in a group therapy session
b. Rotate staff members who work with the client
c. Encourage the client to participate in physical activities
d. Distract the client with increased envi- ronmental stimuli

Answer 52

c. Encourage the client to participate in physical activities

Question 53

A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical eval- uation?
a. Chest x-ray
b. ECG
c. Coagulation studies d. Liver function test

Answer 53

b. ECG

Question 54

A nurse is developing plan of care for a school age child who has ADHD. Which of the following interventions should the nurse include in the plan?

a. Administer olanzapine
b. Institute consequences for deliberate behaviors
c. Provide a stimulating environment
d. Encourage thought stopping tech- niques

Answer 54

c. Provide a stimulating environment

Question 55

A nurse is in a mental health facility is making a plan for discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?

a. Clinical nurse specialist
b. Recreational therapist
c. Social worker
d. Occupational therapist

Answer 55

c. Social worker

Question 56

A nurse is providing crisis interventions for a client who was involved in a violent mass casualty situation int he community. Which of the following actions should the nurse take during the initial session with the client?

a. Encourage the client to display anger toward the cause of the crisis
b. Tell the client that his life will soon return to
normal
c. Identify the client’s usual coping style
d. Help the client focus on a wide variety of topics regarding the crisis

Answer 56

c. Identify the client’s usual coping style

Question 57

A CN is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms?

a. Suppression
b. Reaction formation
c. Identification
d. Compensation

Answer 57

c. Identification