Recalls 5 - NP5

Question 1

1. Nurse Beatrice is assessing a client with a binge eating disorder. Beatrice understands which other comorbidity is commonly found with this disorder?

A. Disorganized behavior
B. Depression
C. Fear of abandonment
D. Perfectionism

Answer 1

B. Depression

Question 2

4. Beatrice is developing group therapy sessions on substance use disorders. She develops weekly topics and plans to host the sessions in a community center. She is in which phase of therapeutic group development?

A. Working
B. Orientation
C. Termination
D. Planning

Answer 2

D. Planning

Question 2

2. Beatrice is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question?

A. Venlafaxine
B. Esomeprazole
C. Topiramate
D. Lurasidone

Answer 2

C. Topiramate

Question 2

5. Beatrice is performing an assessment on a client. The client tells the nurse, “You people are part of the government plotting to destroy me.” She should respond with which appropriate statement?

A. “Would you like me to come back later for your assessment?”
B. “I believe you and think we should explore why you feel this way.”
C. “Tell me more about someone trying to destroy you.”
D. “Let us talk about your current medication and how it can help with those thoughts.”

Answer 2

C. “Tell me more about someone trying to destroy you.”

Question 3

3. Beatrice is caring for a client who has been prescribed sertraline for major depressive disorder. It would be a priority for Beatrice to assess for which of the following?

A. Insomnia
B. Sexual side-effects
C. Weight gain
D. Suicidal ideation

Answer 3

D. Suicidal ideation

Question 3

6. RN Four cares for a client who has missed their last appointment with the doctor. The client states, “I missed my appointment because I overslept, but I knew it would be pointless anyway.” The client is demonstrating which defense mechanism?

A. Projection
B. Reaction formation
C. Denial
D. Rationalization

Answer 3

D. Rationalization

Question 4

7. RN Four is caring for a client newly admitted to the behavioral health unit with anorexia nervosa. He should prioritize monitoring the client’s:

A. coping skills.
B. electrolyte levels.
C. weight.
D. dietary preferences.

Answer 4

B. electrolyte levels.

Question 5

9. Four is caring for a client with uncontrolled generalized anxiety disorder (GAD). Four anticipates the physician will prescribe a selective serotonin reuptake inhibitor (SSRI). Which medication is an SSRI?

A. venlafaxine
B. paroxetine
C. alprazolam
D. duloxetine

Answer 5

B. paroxetine

Question 5

8. RN Four is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should he, as a home health nurse, assess first?

A. Drug intoxication
B. Increased hearing loss
C. Cancer metastases
D. Congestive heart failure

Answer 5

A. Drug intoxication

Question 6

11. Charge nurse Jeanine is developing a plan of care for a child with severe conduct disorder. She should plan to: Select all that apply.

A. anticipate a prescription for stimulant medications.
B. set limits that change based on the nurse that is assigned to the client.
C. construct a behavioral contract between the client and the nurse.
D. have the child apologize to any individuals harmed by their behavior.
E. ignore any attention seeking behavior.
F. supervise any physical activity with other children.

Answer 6

C. construct a behavioral contract between the client and the nurse.

D. have the child apologize to any individuals harmed by their behavior.

E. ignore any attention seeking behavior.

F. supervise any physical activity with other children.

Question 7

10. Four is triaging phone calls at a clinic for a group of clients. Which client situation requires immediate notification to the doctor A client who:

A. reports a strong metallic-like taste while taking newly prescribed metronidazole.
B. reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim.
C. takes prescribed lithium and reports blurred vision.
D. feels restless and reports difficulty sleeping while taking prescribed prednisone.

Answer 7

C. takes prescribed lithium and reports blurred vision.

Question 8

12. Nurse Fear is giving discharge instructions to a client recently diagnosed with vaginitis. Which of the following instructions should the nurse include?

A. Urinate before having sexual intercourse
B. Practice regular douching
C. Clean the vulva with moisturizing soap
D. Wear loose-fitting clothing and cotton underwear

Answer 8

D. Wear loose-fitting clothing and cotton underwear

Question 9

17. Nurse Anger is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?

A. Air humidifier
B. Inner cannula
C. Nasal cannula oxygen
D. Tracheostomy brush

Answer 9

B. Inner cannula

Question 10

13. Nurse Fear has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?

A. Administer analgesics to control pain
B. Monitor for signs of infection
C. Monitor for signs of hypovolemia
D. Ensure that the ascitic fluid is sent to the lab for analysis

Answer 10

C. Monitor for signs of hypovolemia

Question 11

15. Nurse Joy is preparing to administer a unit of packed red blood cells (PRBCs). She should:

A. obtain a bag of 250 mL of 0.9% saline.
B. obtain a bag of 250 mL of Dextrose 5% in water (D5W).
C. insert a 22 gauge intravenous (IV) catheter.
D. initiate continuous telemetry monitoring.

Answer 11

A. obtain a bag of 250 mL of 0.9% saline.

Question 12

14. Nurse Joy is caring for a client who presents to the emergency department with sudden-onset weakness on one side of the body and difficulty speaking. She suspects the client may be experiencing a stroke. Which assessment finding would further support the possibility that the client is experiencing a stroke?

A. Cardiac arrhythmia
B. Orthostatic hypotension
C. Anisocoria
D. Hypoglycemia

Answer 12

C. Anisocoria

Question 13

16. Nurse Anger is caring for a client with an ileostomy. The client reports that the ostomy’s odor is embarrassing. After reviewing the client’s nutritional history, the nurse should recommend that the client avoid consuming:

A. Buttermilk
B. Parsley
C. Yogurt
D. eggs

Answer 13

D. eggs

Question 14

18. Nurse Disgust is counselling a client who has breast cancer. Which tertiary prevention measure should the nurse recommend?

A. Reviewing breast cancer risk factors with the client’s family
B. Assessing the unaffected breast for abnormalities
C. Recommending the client’s daughter get screened for the BRCA1 or BRCA2 gene
D. Attending a local support

Answer 14

D. Attending a local support

Question 15

19. Nurse Disgust suspected a client may have an acute myocardial infarction. Which finding on the electrocardiogram (ECG) abnormality would support this possibility?

A. U-waves
B. T-wave inversion
C. ST-segment elevation
D. Prolonged PR-interval

Answer 15

C. ST-segment elevation

Question 16

20. Nurse Sadness is caring for a client receiving a phenylephrine infusion. Which of the following statements accurately describes the pharmacological action of phenylephrine?

A. Phenylephrine is a neurotransmitter released by the parasympathetic nervous system, primarily involved in the regulation of heart rate and digestion.
B. Phenylephrine is a hormone secreted by the adrenal cortex, primarily responsible for the regulation of blood glucose levels and metabolism.
C. Phenylephrine is a sympathomimetic drug that acts as an alpha-adrenergic agonist, causing vasoconstriction and increasing blood pressure.
D. Phenylephrine is a hormone produced by the posterior pituitary gland, responsible for water retention and blood pressure regulation

Answer 16

C. Phenylephrine is a sympathomimetic drug that acts as an alpha-adrenergic agonist, causing vasoconstriction and increasing blood pressure.

Question 17

22. Nurse Anxiety has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?

A. cocaine intoxication
B. respiratory acidosis
C. tonic-clonic seizures
D. aggression

Answer 17

B. respiratory acidosis

Question 18

21. When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for Nurse Sadness moving forward?

A. Report the conflict to the director of nursing over the unit
B. Report the conflict to the nurse manager of the unit.
C. Report the conflict to the assigned charge nurse of the unit.
D. Discuss the conflict with another nurse to attempt resolution of the issue.

Answer 18

C. Report the conflict to the assigned charge nurse of the unit.

Question 19

24. Nurse Envy is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?

A. Pantoprazole
B. Ciprofloxacin
C. Lactulose
D. Loperamide

Answer 19

B. Ciprofloxacin

Question 19

23. Nurse Anxiety is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected?

A. Stools that contain blood and mucus
B. Pain with urination
C. Episodic upper abdominal pain
D. Hypoactive bowel sounds

Answer 19

C. Episodic upper abdominal pain

Question 20

25. Nurse Envy prepares to care for a client with severe anxiety. The nurse anticipates that the client will demonstrate A. limited problem solving and decreased attentiveness. B. heightened perceptual field and is aware of the anxiety. C. narrowed perceptual field and able to discuss past coping mechanisms D. the inability to problem solve and has a sense of impending doom.

Answer 20

D. the inability to problem solve and has a sense of impending doom.

Question 21

26. Nurse Riley is counselling a client considering scheduling a pap smear. The nurse recommends this test because it screens for: A. ovarian cancer. B. endometrial cancer. C. cervical cancer. D. vaginal cancer.

Answer 21

C. cervical cancer.

Question 22

27. Nurse Riley is caring for a child admitted with a concussion. Which assessment finding would be the earliest in determining the client's worsening neurological status? A. Level of consciousness B. Blood pressure C. Intracranial pressure (ICP) measurement D. Pupil

Answer 22

A. Level of consciousness

Question 23

28. Nurse Embarrassment is assessing a client who has Raynaud’s phenomenon. Which of the following would be an expected finding? A. Digit color changes B. Flapping hand tremor C. Painless skin ulcers D. Janeway lesions

Answer 23

A. Digit color changes

Question 24

29. At an eating disorder treatment center, Nurse Embarrassment is caring for a client with anorexia nervosa who has recently arrived at the facility. Which intervention should the nurse apply following the client's meals? A. Instruct the client to exercise by going for a walk following meals B. Restrict the client from using the restroom for 90 minutes after each meal C. Ask the client to lie down for two hours after each meal D. Encourage the client to begin an intense exercise program, with short exercise sessions after each meal

Answer 24

B. Restrict the client from using the restroom for 90 minutes after each meal

Question 25

30. Nurse Bloofy is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed: A. olanzapine reporting muscle stiffness and feeling hot. B. haloperidol reporting blurred vision and constipation. C. clozapine reporting occasional twitches of the mouth. D. aripiprazole reporting feeling very restless.

Answer 25

A. olanzapine reporting muscle stiffness and feeling hot.

Question 26

34. Charge nurse Jeanine at the school clinic is interviewing a child who is angry and blames their teacher for not passing an exam. The student admits that they did not study for the exam. The child is demonstrating which defense mechanism? A. Undoing B. Projection C. Compensation D. Intellectualization

Answer 26

B. Projection

Question 26

33. Charge nurse Jeanine is teaching a client newly prescribed phenelzine. Which dietary items should she instruct the client to avoid while taking this medication? A. smoked bacon B. scrambled eggs C. milk D. kale

Answer 26

A. smoked bacon

Question 26

32. Charge nurse Jeanine is caring for a client diagnosed with trichotillomania. She anticipates a prescription for which medication from the doctor? A. Fluoxetine B. Amphetamine C. Haloperidol D. Bupropion

Answer 26

A. Fluoxetine

Question 26

31. Nurse Bloofy is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include? A. Applying pneumatic compression B. Inserting an indwelling urinary catheter C. Placing the client on strict bed rest D. Measuring the abdominal

Answer 26

A. Applying pneumatic compression

Question 27

35. Jeanine assists the client in developing goals while hospitalized. This phase of the nurse-client relationship is best described as which of the following? A. Orientation phase B. Working phase C. Termination phase D. Pre-interaction phase

Answer 27

A. Orientation phase

Question 27

36. Nurse Miranda Priestly is caring for a client with schizophrenia and has received a new prescription for clozapine. Prior to administering the first dose, she plans on obtaining the client's: A. weight. B. pulmonary function tests. C. urine analysis. D. visual acuity.

Answer 27

A. weight.

Question 28

37. The psychiatric nurse, Nurse Miranda Priestly, is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to bipolar disorder. She knows that which of the following is the best way to help prevent another unseemly episode? A. Identify the consequences of the behavior. B. Assist the client in understanding triggering events or feelings that may have lead to the outburst. C. Ensure that the patient’s safety is upheld. D. Offer the patient clear options to deal with their current behavior.

Answer 28

B. Assist the client in understanding triggering events or feelings that may have lead to the outburst.

Question 29

38. A client scheduled for hip replacement surgery expresses anxiety to Miranda Priestly regarding the upcoming surgery. Which response by Miranda is most therapeutic? A. “Everyone is nervous before any surgery. What you feel is completely normal.” B. “Here’s what’s going to happen to you during the procedure. I will explain it to you in detail.” C. “Can you tell me what you have been told about the surgery?” D. “Let me tell you about the care you will receive and the pain you should anticipate after the surgery.”

Answer 29

C. “Can you tell me what you have been told about the surgery?”

Question 30

39. Miranda has received a prescription to administer thiamine to a client. Miranda understands that this medication is intended to treat: A. systemic lupus erythematosus. B. pernicious anemia. C. Wernicke's encephalopathy. D. iron deficiency anemia.

Answer 30

C. Wernicke's encephalopathy.

Question 31

40. Priestly is caring for the following assigned clients. She should initially follow-up with the client who: A. is repeatedly washing their hands. B. talking over others during group therapy. C. yelling and shouting at others. D. is voluntarily admitted and requesting discharge.

Answer 31

C. yelling and shouting at others.

Question 32

41. Nurse Andrea Sachs is caring for a client with a history of aggressive and violent behavior. When caring for this client, she should initially take which action? A. Restrain the client B. Place the client in seclusion C. Get an order for a sedating medication D. Establish trust with the client

Answer 32

D. Establish trust with the client

Question 33

42. Andrea Sachs is caring for a client diagnosed with Generalized Anxiety Disorder (GAD). She should anticipate a prescription for which medication? A. Haloperidol B. Fluphenazine C. Buspirone D. Methylphenidate

Answer 33

C. Buspirone

Question 34

45. Your client has just undergone a fecal diversion surgery and will be discharged to their home. Which type of social support person or support network is most likely to benefit this client in terms of post-discharge self-care and physical adaptations necessary for this client? A. A peer support network like an ostomy group in the community to promote self-care B. An emotional support person to help the client cope with the altered bodily image C. An instrumental support network to help with activities of daily living (ADLs) D. A church group of volunteers who can transport the client to doctor appointments

Answer 34

A. A peer support network like an ostomy group in the community to promote self-care

Question 34

43. The most serious adverse effect of tricyclic antidepressant (TCA) overdose is: A. Seizures B. Hyperpyrexia C. Metabolic acidosis D. Cardiac arrhythmias

Answer 34

D. Cardiac arrhythmias

Question 35

44. Andrea is teaching a client newly prescribed buspirone for generalized anxiety disorder. Which of the following client statements would indicate the need for further teaching? A. "It may take a few weeks before I notice a benefit." B. "I should take this medication consistently with or without food." C. "I should take this medication only when my anxiety is at its worst." D. "I may experience nausea while taking this medication."

Answer 35

C. "I should take this medication only when my anxiety is at its worst."

Question 36

46. RN Emily is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client? Select all that apply. A. “Great work today in group therapy Steve, you were really talkative today!” B. “I’d like to just sit with you for a while Steve.” C. “Tell me how you’re feeling Steve. I’d like to understand.” D. “Why are you feeling depressed today Steve?” E. "I know exactly how you feel. I've been through the same thing."

Answer 36

B. “I’d like to just sit with you for a while Steve.” C. “Tell me how you’re feeling Steve. I’d like to understand.”

Question 37

47. Emily in the emergency department (ED) is caring for a client experiencing agitation, anxiety, and hypertension. On assessment, the client has mydriasis and diaphoresis. Emily suspects that this client may be intoxicated with which substance? A. Opioids B. Barbiturates C. Amphetamines D. Cannabis

Answer 37

C. Amphetamines

Question 38

48. Emily is assessing a client who has a borderline personality disorder (BPD). Which of the following would be an expected finding? Select all that apply. A. Self-mutilating behaviors B. Hypervigilance C. Emotional detachment D. Social inhibition E. Impulsivity

Answer 38

A. Self-mutilating behaviors

Question 39

49. She cares for a client who is mechanically ventilated and receives multiple intravenous medications. The client's family member is upset and overwhelmed by the client's clinical condition. Which therapeutic action would be appropriate for her to take? A. Let the family member spend time alone with the client B. Reminiscence with the family member about the client C. Ask the family member if they would like to speak with pastoral care D. Explain the different types of medications and therapies the client is receiving

Answer 39

D. Explain the different types of medications and therapies the client is receiving

Question 40

50. She is caring for a client with Alzheimer's disease and is approached by the client's family member, stating, "I'm so tired of hearing Dad talk about the past." She should inform the family member that: A. "You should be more patient with your father and accepting of his disease." B. "Changing the subject to avoid reminiscing may be helpful." C. "He has lost his short-term memory but can still remember events from long ago." D. "Just remind him when he repeats himself and that will reinforce better behavior."

Answer 40

C. "He has lost his short-term memory but can still remember events from long ago."

Question 41

51. Student nurse Nigel is evaluating laboratory data for a client taking lithium. Which laboratory data requires immediate follow-up? A. white blood cell (WBC) count, 11,500 mm3 B. fasting blood glucose 112 mg/dL C. creatinine 1.6 mg/dL D. free thyroxine T4 (FT4) 0.6 ng/dL

Answer 41

C. creatinine 1.6 mg/dL

Question 42

52. Student nurse Nigel is designing a care plan for a client involuntarily admitted with severe major depressive disorder. A critical aspect of this client’s plan of care is: A. the participation of the client. B. a completed medication reconciliation. C. a review of previously prescribed antidepressant medications. D. the assignment of a case manager.

Answer 42

A. the participation of the client.

Question 43

54. Student nurse Nigel in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for Nigel? A. Restrain the client B. Escort the other clients from the room C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption D. Approach the client causing a disruption calmly while accompanied by two additional staff members

Answer 43

D. Approach the client causing a disruption calmly while accompanied by two additional staff members

Question 44

53. Student nurse Nigel is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Verapamil

Answer 44

B. Hydrochlorothiazide

Question 45

55. Nigel is conducting a suicide assessment on a client. While reviewing the assessment data, Nigel is most concerned about the client A. having alcohol dependence. B. taking an antidepressant for the past five years. C. newly diagnosed with psoriasis. D. just started attending a support group for individuals with psoriasis.

Answer 45

A. having alcohol dependence.

Question 46

56. Jacqueline is a nurse who is caring for a client who is receiving prescribed aripiprazole. Which of the following client findings would indicate a therapeutic response? A. Reports of no hallucinations and delusions B. Increased concentration and attention C. Improved muscle coordination and gait D. No reports of insomnia or night terrors

Answer 46

A. Reports of no hallucinations and delusions

Question 47

57. Jacqueline is talking to new volunteers at an elderly community club regarding elder abuse. Jacqueline identifies which of the volunteer's clients as the one that is most vulnerable to abuse? A. A 75-year-old man that has diabetes B. A 79-year-old man with cataracts C. An 87-year-old woman with Parkinson’s disease D. A 64-year-old woman with psoriasis

Answer 47

C. An 87-year-old woman with Parkinson’s disease

Question 48

59. Jacqueline is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply. A. Promote client autonomy B. Maintain family dynamics and support C. Maintains privacy and confidentiality D. Prevent potential intimidation or coercion E. Minimize the risk of retribution

Answer 48

D. Prevent potential intimidation or coercion

Question 48

58. Jacqueline is caring for a client diagnosed with attention deficit hyperactivity disorder (ADHD). She should anticipate a prescription for which medication? A. Citalopram B. Risperidone C. Methylphenidate D. Carbamazepine

Answer 48

C. Methylphenidate

Question 49

60. She cares for a client with narcolepsy. Which of the following medications would she anticipate the doctor to prescribe? A. aripiprazole B. modafinil C. ropinirole D. quetiapine

Answer 49

B. modafinil

Question 50

61. Nurse Cersei is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates: A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

Answer 50

D. decreased thoughts of persecution.

Question 51

62. Cersei, the head nurse of Lannister Hospital, is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. Obtain a 12-lead electrocardiogram B. Request a prescription to consult psychiatry C. Determine the reasoning for the overdose D. Establish a therapeutic relationship

Answer 51

A. Obtain a 12-lead electrocardiogram

Question 52

63. Cersei is assessing a child with suspected attention-deficit/hyperactivity disorder (ADHD). Which of the following findings would support a diagnosis of ADHD? A. waxy flexibility B. distorted perception of one's body shape C. daytime sleepiness D. forgetfulness

Answer 52

D. forgetfulness

Question 53

65. Cersei is conducting client education regarding medication for a client receiving a monoamine oxidase inhibitor (MAOI). Which of the following should the client avoid? A. Cream cheese B. Swiss cheese C. Milk D. Ice cream

Answer 53

B. Swiss cheese

Question 54

64. Cersei provides education to a group of adolescents about the dangers of heroin use. Which of the following statements by one of the adolescents indicates a need for further clarification? A. "Heroin can lead to addiction and dependence, making it difficult to stop using." B. "Injecting heroin increases the risk of contracting blood-borne infections such as HIV and hepatitis." C. "Heroin can cause respiratory depression, which can be life-threatening." D. "Using heroin with friends at a party is safer than using it alone."

Answer 54

D. "Using heroin with friends at a party is safer than using it alone."

Question 55

66. Tyrion cares for a client who is receiving prescribed citalopram. Which of the following findings would indicate a therapeutic response? A. Improved muscle coordination B. Circumstantial speech pattern C. Longer attention span D. Increased self-esteem

Answer 55

D. Increased self-esteem

Question 56

67. Tyrion is caring for a client who recently experienced a significant role change due to retirement. Which action would appropriately support this client during this transition? A. Providing the client with resources to explore community-based support groups for retirees. B. Advising the client to focus solely on reminiscing about past career achievements. C. Scheduling family visits without consulting the client's preferences. D. Encouraging the client to avoid discussing retirement to prevent emotional distress.

Answer 56

A. Providing the client with resources to explore community-based support groups for retirees.

Question 57

68. Tyrion is assessing a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." He interprets this statement as a: A. delusion of reference. B. delusion of persecution. C. delusion of grandeur. D. delusion of erotomania

Answer 57

B. delusion of persecution.

Question 57

69. Tyrion, a wise educator, is shadowing a student nurse caring for a psychiatric client. He should instruct the student that a therapeutic nurse-client relationship starts with: A. A sincere desire to help others B. Acceptance C. Understanding and self-awareness D. Knowledge of psychiatric nursing

Answer 57

C. Understanding and self-awareness

Question 58

70. Tyrion is reviewing eating disorders with a group of students. It would be correct for him to identify that the primary differential between anorexia nervosa and bulimia nervosa is a client's A. dentition. B. body mass index (BMI). C. binging and purging patterns. D. distorted perception of body weight.

Answer 58

B. body mass index (BMI).

Question 58

71. RN Daenerys is educating a new graduate nurse on different forms of therapeutic communication. Select the form of therapeutic communication which is accurately paired with the correct description of that form of therapeutic communication. A. Seeking Clarification: Utilizing open-ended questions rather than closed-ended questions B. Offering General Leads: Ensuring the client fully understands the sent message C. Reflection: By repeating the client's words back to the client, the nurse conveys that they are actively listening while concurrently encouraging further expression from the client D. Offering Self: Giving the client advice based on the opinion of the nurse

Answer 58

C. Reflection: By repeating the client's words back to the client, the nurse conveys that they are actively listening while concurrently encouraging further expression from the client

Question 59

72. Daenerys has provided medication instructions to a client who has been prescribed venlafaxine. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? Select all that apply. A. “I may not notice an improvement in my mood right away.” B. “This medication may lower my blood pressure.” C. “If I have thoughts of harming myself, I should call 911.” D. “I will need to have weekly laboratory tests.” E. “I may continue taking St. John’s Wort.”

Answer 59

A. “I may not notice an improvement in my mood right away.” C. “If I have thoughts of harming myself, I should call 911.”

Question 60

73. Daenerys is caring for an involuntarily admitted client with an order for electroconvulsive therapy (ECT). Before transferring the client to the procedure room, Daenerys notes that the consent form is unsigned. The nurse understands that: A. Informed consent should be obtained from the client's spouse. B. Informed consent should be obtained from the client. C. Informed consent is not required. D. Informed consent needs to be obtained from the court.

Answer 60

B. Informed consent should be obtained from the client.

Question 61

74. Daenerys is caring for a client in the mental health unit who has become verbally aggressive with other clients while in the dining room. Which statement would be appropriate for her to make to the client? A. "Let's discuss your concerns in a private room with the door closed." B. “Do you want to go to your room or to the quiet room for a while?” C. "I think you should take a few minutes to calm down." D. “What is going on right now?”

Answer 61

B. “Do you want to go to your room or to the quiet room for a while?”

Question 62

75. The husband of a client diagnosed with a brain tumor tells Daenerys, "I don't think I can make it if something happens to my wife. I love her so much." What is the most appropriate response from her? A. “Let me call the chaplain to come and talk to you.” B. “Do you have any family support to be with you?” C. “What makes you think you won't be able to make it?” D. “Do not worry, everything will be all right. You are a strong man.”

Answer 62

C. “What makes you think you won't be able to make it?”

Question 63

76. Nurse Jon Snow is caring for a client who was just informed that they tested positive for human immunodeficiency virus (HIV). The client is demonstrating denial of the laboratory result by stating it was a mistake. Jon Snow should: A. arrange for the blood specimen to be retested. B. provide the client with a paper copy of the test result. C. arrange for the client to join a support group. D. recognize that this defense mechanism is commonly used during this time.

Answer 63

D. recognize that this defense mechanism is commonly used during this time.

Question 64

77. Jon Snow is caring for a client receiving hospice services. The client states “I feel no real connection with God.” Which action should he take? A. Give the client a hug and tell them that their life still has meaning B. Arrange for a spiritual adviser to visit the client C. Ask the client if they would like to talk about their feelings D. Call in a close friend or relative to talk with the client

Answer 64

C. Ask the client if they would like to talk about their feelings

Question 65

78. Jon Snow is caring for a client who underwent extensive reconstructive surgery following a severe burn injury. The client expresses distress over their altered appearance and avoids social interactions. Which nursing intervention is most appropriate to address the client's altered body image? A. Encourage the client to avoid looking at themselves in the mirror to minimize distress. B. Provide opportunities for the client to express their feelings and concerns about their appearance. C. Advise the client to focus solely on physical recovery and disregard their emotional state. D. Suggest the client wear clothing that conceals the surgical scars to avoid drawing attention.

Answer 65

B. Provide opportunities for the client to express their feelings and concerns about their appearance.

Question 66

79. While preparing to change the dressing of a female patient with end-stage renal disease, Jon Snow notices that the patient's son is silently holding her hand and praying. Which of the following should be his initial action? A. Continue preparing for the procedure in the room. B. Notify the chaplain. C. Leave the room quietly and come back after 15 minutes to change the client’s dressing. D. Ask the son if he wants the nurse to join in prayer.

Answer 66

C. Leave the room quietly and come back after 15 minutes to change the client’s dressing.

Question 67

80. Jon receives a prescription for sertraline. He understands that this medication is used to treat which condition? A. Schizophrenia B. Bipolar disorder C. Bulimia D. Major depressive disorder

Answer 67

D. Major depressive disorder

Question 68

81. Jaime, RN, is teaching a group of students about using reminiscence therapy. Which statements should Jaime include in the teaching? Select all that apply. A. This approach helps support self-esteem B. This is an effective intervention in a group setting C. This intervention focuses on looking forward D. Establishing future goals is important part of this intervention E. Reminiscing is a way to express personal identity

Answer 68

A. This approach helps support self-esteem B. This is an effective intervention in a group setting E. Reminiscing is a way to express personal identity

Question 69

82. Jaime is caring for a client prescribed a monoamine oxidase inhibitor (MAOI). During the therapy, He recommends that the client monitor their: A. blood pressure. B. pulse. C. capillary blood glucose. D. daily weight.

Answer 69

A. blood pressure.

Question 70

83. Jaime cares for a client who is asking about advanced directives. Many documents fall under the category of an advanced directive. The nurse knows that one of the most common legal papers is called 'Durable Power of Attorney for Health Care' and works to: A. Review a person’s personal preferences for medical care in the future. B. Authorize another person to make medical decisions for a person if they become unable to on their own. C. Assign a legal authority in making medical decisions while honoring the spoken word of the family. D. Define what care should be administered or withheld by health care professionals, no matter which medical facility the patient finds themselves in.

Answer 70

B. Authorize another person to make medical decisions for a person if they become unable to on their own.

Question 71

84. Jaime, a nurse manager, plans to develop a unit-based council to assist in decision-making. He is demonstrating which leadership style? A. Authoritative B. Democratic C. Laissez-Faire D. Transactional

Answer 71

B. Democratic

Question 72

85. Jaime is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity? A. REM sleep B. Circadian rhythm C. Diurnal rhythm D. Nocturnal activity

Answer 72

B. Circadian rhythm

Question 73

87. Sansa provides postmortem care to a deceased client. Which action is appropriate during postmortem care? A. Elevating the head of the bed for easier family viewing. B. Performing mouth care to maintain oral hygiene. C. Applying lotion to the skin to prevent postmortem changes. D. Removing any identification tags before notifying the family.

Answer 73

A. Elevating the head of the bed for easier family viewing.

Question 74

86. Sansa is working with a client who suffers from obsessive-compulsive disorder (OCD). The client is obsessed with the dangers of germs and performs compulsive hand washing hundreds of times per day. Which of the following should the Nurse Sansa include in this client’s treatment plan? Select all that apply. A. Create a schedule for the hand washing ritual. B. Teach the client about the dangers of over washing their hands. C. Incorporate meditation into their daily schedule. D. Block the sink so the client is not tempted to wash their hands. E. Administer fluoxetine as ordered.

Answer 74

A. Create a schedule for the hand washing ritual.

Question 75

88. Sansa is reviewing acetaminophen toxicity with students. Sansa should remind students that the maximum acetaminophen dosage for an adult is: A. 2,000 mg per day B. 4,000 mg per day C. 5,000 mg per day D. 6,000 mg per day

Answer 75

B. 4,000 mg per day

Question 76

89. Sansa is assessing a group of clients prescribed lithium. The client at most significant risk for lithium toxicity is a client with: A. asthma taking both long- and short-acting bronchodilators. B. chronic migraine headaches and was newly prescribed naproxen. C. hypertension newly prescribed clonidine transdermal patch. D. hypothyroidism and was recently prescribed levothyroxine.

Answer 76

B. chronic migraine headaches and was newly prescribed naproxen.

Question 77

90. The doctor prescribes dopamine at 5 mcg/kg/minute. The client weighs 178 lbs. The medication label reads dopamine 800 mg in 500 mL of dextrose 5% water (D5W). Help Nurse Sansa. How many mL per hour will be administered to the client? Round your answer to the nearest whole number. A. 25 B. 30 C. 65 D. 75

Answer 77

A. 25

Question 78

92. Arya is caring for a child who has autism. Which of the following actions should the Arya take? Select all that apply. A. Have a family member bring in the child's favorite toys B. Dim the lights in the room Seclude the child for any misconduct C. Maintain consistent caregivers D. Withhold prescribed vaccines

Answer 78

B. Dim the lights in the room D. Withhold prescribed vaccines

Question 78

91. Arya Stark is a nurse assessing a client with post-traumatic stress disorder (PTSD). Which assessment finding would be expected? A. Delusions of grandeur B. Hypervigilance C. Circumstantial speech D. Flight of ideas

Answer 78

B. Hypervigilance

Question 79

93. Arya is caring for a client with schizophrenia. Arya should anticipate a prescription for which medication? A. Lithium B. Bupropion C. Sertraline D. Risperidone

Answer 79

D. Risperidone

Question 80

94. Arya is caring for a client with bulimia nervosa. Which newly prescribed medication requires clarification with the doctor? A. fluoxetine B. bupropion C. sertraline D. fluvoxamine

Answer 80

B. bupropion

Question 81

95. Arya cares for assigned clients. She should recognize that the client at greatest risk for compartment syndrome is the client who has which of the following? A. A left tibial fracture that was recently placed in a cast B. Swelling in the ankles and is wearing compression stockings C. Chronic osteomyelitis of the right femur D. Skin traction following a left hip fracture

Answer 81

A. A left tibial fracture that was recently placed in a cast

Question 82

96. Nurse Bran is caring for assigned clients in the behavioral health unit. He should initially assess the client who: A. has postpartum depression who appears unkempt and dejected. B. recently lost their family in an accident and currently states, "I want to be with them." C. has anorexia nervosa and demands that she get reweighed. D. refused their second dose of prescribed lithium because of a fine hand tremor.

Answer 82

B. recently lost their family in an accident and currently states, "I want to be with them."

Question 83

97. Bran is assessing a client with Dependent Personality Disorder. Which of the following would be an expected finding? Select all that apply. A. Difficulty with decision-making B. Flamboyant behaviors C. Intense and unstable relationships D. Avoiding social relationships E. Feels helpless when alone

Answer 83

A. Difficulty with decision-making

Question 84

98. Bran is educating staff on antipsychotics. It would be correct to identify which medication is a typical (first generation) antipsychotic? Select all that apply. A. Chlorpromazine B. Olanzapine C. Risperidone D. Fluphenazine E. Clozapine F. Haloperidol

Answer 84

A. Chlorpromazine D. Fluphenazine F. Haloperidol

Question 85

99. Bran is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, Bran should prioritize reviewing the client's: A. vital signs. B. height and weight. C. family medical history. D. current medications.

Answer 85

D. current medications.

Question 86

100. Bran is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which of the following responses would be most appropriate for Bran to make to the client? A. “What you are experiencing is not real.” B. “Are you hearing voices?” C. "You are safe here, please be calm.” D. “What makes you think we are trying to kill you?”

Answer 86

D. “What makes you think we are trying to kill you?”