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1.

A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in a client's 8. A nurse is assessing a client who has delirium. Which of the following findings requires
history should the nurse report to provider? immediate intervention by the nurse?
a. Recent head injury - risk for seizures a. Rapid mood swings
b. Hypothyroidism b. Inappropriate speech patterns
c. Hippie infection c. Command hallucinations
d. Knee arthroplasty 1 month ago d. Impaired memory

2. A nurse is planning care for a client who has narcissistic personality disorder. Which of 9. A nurse in an emergency department is assessing a client who recently reported using
the following actions is appropriate for the nurse to include in the plan of care? cocaine. Which of the following clinical manifestations should the nurse?
a. Request an anti-psychotic medication from the provider a. Lethargy
b. Ask the client to sign a no suicide contract b. Bradycardia
c. Remain neutral when communicating with the client c. Hypertension
d. Provide the client with high calorie finger foods d. Hypothermia

3. A nurse is preparing for an interprofessional team meeting regarding client who has major 10. A nurse is teaching a client about the use of cognitive reframing for Stress Management.
depressive disorder. Which of the following findings obtained during the initial assessment Which of the following statements been a client indicates an understanding of the
is a priority to report to other disciplines? teaching?
a. Significant weight loss a. I will practice replacing negative thoughts with positive self statements
b. Neglected hygiene b. I will progressively relax each of my muscle groups when feeling stressed
c. Psychomotor retardation c. I will focus on a mental image while concentrating on my breathing
d. Problem solving skills d. I will learn how to voluntarily control my blood pressure and heart rate

4. A nurse in a mental health facility is reviewing a client's medical record. Which of the 11. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
following actions should the nurse take first? EXHIBIT and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
a. Initiate 0.9% sodium chloride with 40 mil equivalent potassium chloride a. High fever
b. Encourage the client to attend group therapy sessions b. Urinary hesitancy
c. Teach the client about nutritional needs c. Insomnia
d. Administer acetaminophen 500 mg PO d. Headache

5. A nurse is planning care for a client who demonstrates prolonged depression related to the 12. A nurse is interviewing a client who was recently sexual assaulted. The client cannot recall
loss of her partner 6 months ago. Which of the following actions should the nurse take? the attack. The nurse should identify the the client is using which of the following defense
a. Suggest that the client avoid social interactions that remind her of her partner mechanisms?
b. Discourage the client from reliving the events surrounding her loss a. Suppression
c. Explain that it can take a year or more to learn to live with a loss b. Reaction Formation
d. The client to maintain an unstructured daily routine c. Sublimation
d. Repression
6. A nurse is teaching a client who has a new prescription for disulfiram. Which of the
following statements by the client indicates an understanding of the teaching? 13. A nurse is caring for a client who has Alzheimer's disease. Which of the following
a. I can continue to eat age cheese and chocolate findings should the nurse expect?
b. I can wear my cologne on special occasions a. Excessive motor activity
c. When I bake my favorite cookies, I can use pure vanilla extract for flavoring b. Altered LOC
d. If I cut myself I can clean the wound with isopropyl alcohol c. Failure to recognize familiar objects
i. Avoid everything that has alcohol d. Rapid mood swings

7. A nurse is caring for a client who has schizophrenia and is experiencing auditory 14. A nurse in a mental health facility is caring for a client who is being aggressive toward
hallucinations. Which of the following actions should the nurse take first? other clients. Which of the following actions is a priority for the nurse to take?
a. Focus the client on reality-based topics a. Ask the client if he intends to harm others
b. Monitor the client for indication of anxiety b. Role model healthy ways to express anger
c. Ask the client what she is hearing c. Assist the client to explore techniques to reduce stress
d. Encourage the client to listen to music d. Suggest that the client make a list of things that make him angry
22. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of
15. A nurse is assisting with obtaining informed consent for a client who has been declared rooms, speaking inappropriately, and giggling. Which of the following actions should the
legally incompetent. Which of the following actions should the nurse take? nurse take?
a. Request of the client’s guardian sign the consent a. Tell the client will be negative consequences for her behavior
b. Ask the charge nurse to obtain informed consent b. Have the client return to her room to read a book
c. Contact the social worker to obtain the consent i. Do not involve client w/ something that requires high level of
d. Explain implied consent to the client’s family concentration
c. Lead the client outside for a walk - “provide outlet for physical activity”
16. A nurse is developing a plan of care for school-age child has autism spectrum disorder. d. Take the client to the day room to watch a movie with other clients
Which of the following interventions should the nurse include in the plan?
a. Assign a child to a room with another child of the same age 23. A nurse is admitting a client who has a new diagnosis of schizophrenia and history of
b. Discourage the child from making eye contact with caregivers aggression. Which of the following actions should the nurse include in the client’s initial
c. Allow flexibility in the child's daily schedule plan of care?
d. Use a reward system for appropriate behavior a. Ignore the clients hallucinations - should assess
b. Agree with the client when he's upset until he can calm down - never agree
17. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of c. Avoid eye contact with the client for the first few days - therapeutic comm
the following findings indicates a need for hospitalization? d. Provide a physical exercise activity for the client - distracts the client
a. Potassium 3.8
b. HR 56/min 24. A nurse is caring for a client who begins yelling and pacing around the room. Which of the
c. Temperature 96.1 F following actions should the nurse take? SATA
d. Weight 10% below ideal weight a. Stand directly in front of the client
b. Speak to the client in a loud voice
18. A nurse is caring for a client who has severe depression and is scheduled to receive c. Request that security guards restrain the client
electroconvulsive therapy. The nurse should recognize that the client will receive d. Identify the clients stressors
succinylcholine to prevent which of the following adverse effects? e. Talk to the client using short, simple sentences
a. Muscle distress
b. Aspiration 25. A nurse is observing a newly licensed nurse administer an IM medication to a client who
c. Elevated blood pressure is manic and refuses the medication. Which of the following actions should the nurse take
d. Decrease heart rate first?
a. Talk to the newly licensed nurse about the incident
19. A nurse is developing a plan of care for a client who has paranoid personality disorder. b. Call the provider for an alternate medication route
Which of the following actions should the nurse include in the plan? c. Stop the newly licensed nurse from administering the medication
a. Provide written information about the client’s treatment plan d. Report the occurrence to the nurse manager
b. Monitor the client for splitting behaviors
c. Encourage countertransference when developing the nurse client relationship 26. A nurse is teaching the family of a client who has Alzheimer's disease about safety
d. Isolate the client from social or group interactions interventions for nighttime wandering. Which of the following interventions should the
nurse include?
20. A nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss a. Install locks at the bottom of the exit doors - top
the client's condition. Which of the following is appropriate nursing action? b. Place a client's mattress on the floor
a. Consult the client's family c. Encourage the client to take naps during the day - noooo
b. Contact the facility legal department d. Place rubber back throw rugs on the tile floors - fall risk
c. Contact the provider
d. Consult the client 27. A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart
exploded and my blood is draining out.” The nurse should interpret the statement as
21. A nurse in the emergency department is caring for a client who has serotonin syndrome. which of the following manifestations?
The nurse should assess the client for which of the following manifestations? a. A somatic delusion
a. Bradycardia - tachycardia b. A visual hallucination
b. Priapism c. Concrete thinking
c. Paresthesia d. Paranoia
d. Hyperpyrexia - temp >104F
28. A nurse is preparing to administer methylphenidate 25 mg PO to school age child who has 35. A nurse is planning to lead a support group for clients have alcohol use disorder. One of
ADHD. Avail is 10 mg/5mL. How many mL? ( Round to the nearest tenth ) the group members is a client who speaks a different language than the nurse. The nurse
a. 12.5 mL should ask which of the following individuals to assist with communication?
a. A translator of the same gender as the client
29. A nurse is creating a plan of care for a client who has major depressive disorder. Which of b. A unit secretary who speaks the same language as the client
the following interventions should the nurse include in the plan? c. A family member of the client - never
a. Encourage physical activity for the client during the day - yay endorphins d. Another client who speaks the same language as the client - no
b. Discourage the client from expressing feelings of anger
c. Keep a bright light on in the client’s room at night 36. A nurse on a mental health unit is leading a therapy session for group of clients. One client
d. Identify and schedule alternate group activities for the client challenges the nurse and shows no empathy for others in the group. Which of the
following actions should the nurse take?
30. A nurse is caring for a client who has generalized anxiety disorder and a history of a. Request of the client leave the therapy session immediately
substance use disorder. Which of the following medications should the nurse expect the b. Ask the client privately what is causing the anger
provider to prescribe? c. Place the client in seclusion
a. Clonazepam - benzo/seizures/prevention and tx of alch w/drawals d. Reassign the client to another group
b. Buspirone - anxiolytic/OCD/GAD
c. Alprazolam - benzo/seizures/prevention and tx of alch w/drawals 37. A nurse is caring for a client who states, “Things will never work out.” Which of the
d. Chlordiazepoxide - benzo/seizures/prevention and tx of alch w/drawals following responses should the nurse make?
a. Why do you feel like things will never work out?
31. A nurse in a mental health facility is interviewing a new client. Which of the following b. You should try to focus on yourself for a change
outcomes must occur if the nurse is to establish a therapeutic nurse client relationship? c. Have you been thinking about harming yourself?
a. A written contract is established to clarify the steps of the treatment plan d. Maybe an antidepressant will make you feel better
b. The nurse is seen as an authority figure
c. The nurse is seen as a friend 38. A nurse in an emergency department is creating a plan of care for a client who reports
d. The nurse maintains confidentiality unless the client's safety is experiencing intimate partner violence. Which of the following interventions should the
compromised - first establish trust nurse include as a priority?
a. Refer the client to a support group
32. An older adult client is brought to the mental health clinic by her daughter. The daughter b. Follow the facility’s protocol for reporting the abuse
reports that her mother is not eating and seems uninterested in routine activities. The c. Teach the client stress reduction techniques
daughter states, “I am so worried that my mother is depressed.” Which of the following d. Help the client devise a safe plan
responses should the nurse make? 39. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
a. Tell me the reasons you think your mother is depressed Which of the following statements by the client indicates an accurate understanding of this
b. You shouldn't worry about this, because depressive disorder is easily treated medication’s effects?
c. Everyone gets depressed from time to time a. I know that I will be able to think more clearly now - stimulates CNS
d. Older adults are usually diagnosed with depressive disorder as they age b. I need to tell my doctor if I start gaining weight - weight loss
33. A nurse in a mental health facility is making plans for client discharge. Which of the c. I'll take my medicine at bedtime because it will make me drowsy
following interdisciplinary team members should the nurse contact to assist a client with i. Take last dose before 4pm
housing placement? d. This medicine will help me relax and feel less anxious
a. Clinical nurse specialist i. Used to increase ability to focus, complete tasks, interact w peers
b. Recreational therapist and manage impulsivity
c. Occupational therapist
d. Social worker 40. A nurse is developing a safety plan for client who has experience intimate-partner abuse.
Which of the following items should the nurse include in the plan that will provide
34. A nurse is reviewing the medication administration record of a client who has major immediate safety for the client and her children?
depressive disorder and a new prescription for selegiline. The nurse should recognize that a. The phone number of the local shelter
which of the following client medications is contraindicated when taking with selegiline? b. A code phrase to use when it is time to leave the house
a. Warfarin c. The phone numbers for law enforcement agency
b. Calcium carbonate d. A referral to a support group
c. Acetaminophen
d. Fluoxetine - SSRI: contraindicated when taking MAOI = hypertensive crisis 41. A nurse in a long-term care facility is assessing an older client for depression. Which of
the following findings should the nurse expect?
a. Rambling speech
b. Sundowning 48. A nurse in an acute care facility is planning care for a client who has a history of alcohol
c. Rapid mood swings use disorder and is admitted while intoxicated. Which of the following interventions
d. Insomnia? should the nurse plan for the client?
a. Implement seizure precautions
42. A nurse is caring for a client who is under observation for suicidal ideation and has b. Acidify the client’s urine
verbalized a suicide plan. The client demands privacy and to be left alone. Which of the c. Monitor for orthostatic hypotension
following statements should the nurse make? d. Administer methadone hydrochloride
a. We are concerned about you and need to keep you safe
b. Since you are trying to follow the treatment plan, we can submit your request 49. A nurse is caring for a client who has PTSD. Which of the following clinical findings is
to the provider associated with this disorder?
c. If you complete a no-suicide contract that states you will not harm yourself, a. Hyper-vigilance
you can be alone. b. Depersonalization
d. Until your medication has reached therapeutic levels, you will need constant c. Pressured speech
observation d. Compulsive Behavior

43. A nurse a mental health clinic is assessing a client who has borderline personality disorder. 50. A nurse in the ED is admitting a client who has a history of alcohol use disorder. The
Which of the following findings should the nurse expect? client has a blood alcohol level of 0.26 g/dL. the nurse should anticipate a prescription for
a. Avoidance of interpersonal relationships which of the following medications?
b. Reluctance to discard worthless objects a. Acamprosate - alcohol abstinence
c. Inability to maintain employment b. Naltrexone - alcohol abstinence
d. Intense efforts to avoid abandonment - fear of abandonment c. Chlordiazepoxide - w/drawal sx
d. Disulfiram - maintains abstinence from alcohol
44. A nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of
the following findings should the nurse expect? 51. A nurse is developing a teaching plan for the family of an older client who is to receive
a. Disorganized speech transcranial magnetic stimulation. Which of the following information should the nurse
b. Hypersomnia include in the teaching plan?
c. Heightened concentration a. The client might have a headache after treatment
d. Agoraphobia b. The client will experience a seizure during treatment
c. The client will require intubation after treatment
45. A nurse is caring for a client who receives Lamotrigine daily for bipolar disorder and d. The client is at risk for aspiration during treatment
reports a rash on his arm. Which of the following actions should the nurse take?
a. Explain that the medication causes of temporary rash 52. A nurse is caring for a school-age child who has a fractured arm. The child has other
b. Apply hydrocortisone cream on the clients rash injuries that cause the nurse to suspect abuse. Which of the following actions is
c. Withhold the next dose of the medication appropriate for the nurse to take when assessing the child’s situation?
d. Ask the client about a recent change in laundry detergent a. Ask clarifying questions as a child explains how the injuries occurred
b. Direct the parents to the waiting room before interviewing the child
46. A nurse is assessing a client who has bulimia nervosa. Which of the following findings c. Interview the child with the provider and social worker present
should the nurse expect? d. Ask the parents directly if the child's fracture is due to physical abuse
a. Acrocyanosis
b. Lanugo (anorexia) 53. A nurse in a mental health facility is assessing a client for suicide risk factors using the
c. Hyponatremia - purging = loss of electrolytes SAD PERSONS scale. Which of the following findings indicates the risk for suicide?
d. Amenorrhea (anorexia) a. The client is 50 years old
b. Client has diabetes mellitus
47. A nurse is caring for a client who has schizophrenia and has been taking promazine for 5 c. Female
years. Which of the following assessment tools should the nurse use to determine if the d. Married
client is experiencing adverse effects of the medication?
a. Abnormal involuntary movement scale AIMS - Tardive 54. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly
b. Hamilton depression scale checks that the doors unlocked at night. Which of the following instructions should the
c. Mood disorder questionnaire MDQ nurse give the client when using thought stopping technique?
d. Addiction severity index ASI
a. Snap a rubber band on your wrist when you think about checking the
locks 61. A nurse is reviewing the lab report of a client who is taking carbamazepine for bipolar
b. Ask a family member to check the locks for you at night disorder. Which of the following lab results should the nurse report to the provider?
c. Focus on abdominal breathing whenever you go to check the locks a. Urine specific gravity 1.029
d. Keep a journal of how often you check the locks b. Platelets 90,000/mm3
c. Urine pH 5.6
55. A nurse in a long term care facility is assessing a client who has dementia. Which of the d. RBC 4.7/mm3
following findings should the nurse identify as a risk for the client?
a. The bed in the low position 62. A nurse is caring for a client who reports smoking marijuana several times a day. The
b. The room has an area rug client tells the nurse, “ I don’t know what the big deal is, it is a harmless herb.” The nurse
c. Hallways are long distances should identify that the client is displaying which of the following mechanisms?
d. Outside doors have locks a. Rationalization
b. Suppression
56. A nurse is caring for a client who reports that he is angry with his partner because she c. Reaction Formation
thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he d. Compensation
becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating? 63. After assessing a client in a crisis situation, a nurse determines the client is safe. Which of
a. Denial the following actions should the nurse take first?
b. Rationalization a. Teach the client specific coping skills to handle stressful situations
c. Compensations b. Help the client identify social support
d. Displacement c. Involve the client in planning interventions
d. Assist the client to lower his anxiety level
57. A nurse is assessing a client for negative manifestations of schizophrenia. Which of the
following findings should the nurse expect? 64. A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client
a. Echopraxia reports an inability to sit still. Which of the following should the nurse suspect?
b. Tangentiality a. Tardive dyskinesia
c. Anergia - lack of energy b. Acute dystonia
d. Delusions c. Pseudoparkinsonism
d. Akathisia - unable to sit/stand still
58. A nurse is caring for a client who has physical restraints applied. The nurse determines
that the restraints should be removed when which of the following occurs? 65. A nurse is assessing a client who has antisocial personality disorder. Which of the
a. The client is able to follow commands? following client behaviors should the nurse expect?
b. The client states that he will harm himself unless the restraints are removed a. Attention seeking
c. The client refuses to take his medication until he is released b. Manipulative
d. The client demonstrates that he is oriented to person, place and time c. Anxious
d. Projects blame
59. A nurse is interviewing a client who has schizophrenia. The client states, “Aliens are going
to abduct me at midnight tonight.” Which of the following responses should the nurse 66. A nurse in an ED is caring for a client who reports a recent sexual assault by her partner.
make? Which of the following statements is the priority for the nurse to make?
a. Have you ever been abducted by aliens before? a. I want you to know that you are in a safe place here
b. You are safe from the aliens here b. I can provide info about an advocacy group in your area
c. Why are the aliens going to abduct you? c. A trained sexual assault nurse will be assigned to your care
d. Believing that aliens will abduct you must be scary d. I can contact a support person for you

60. A nurse is building a therapeutic relationship with a client who has an eating disorder. 67. A nurse is providing crisis intervention for a client who was involved in a violent mass
Which of the following activities would the nurse initiate during the relationship’s casualty situation in the community. Which of the following should the nurse take during
orientation phase? the initial session with the client?
a. Teaching and encouraging the use of problem solving skills a. Identify the client's usual coping style
b. Discussing the incorporation of new strategies into daily life b. Tell the client that his life will soon return to normal
c. Using memories to validate the relationship experience c. Encourage the client to display anger toward the cause of the crisis
d. Mutually deciding and agreeing on the goals of the relationship d. Help the client focus on a wide variety of topics regarding the crisis
68. A nurse is providing teaching to a client who has a new prescription for tranylcypromine.
Which of the following OTC meds should the nurse instruct the client to avoid taking due
to adverse interactions?
a. Magnesium hydroxide
b. Pseudoephedrine
c. Ranitidine - h2 receptor
d. Ibuprofen

69. A nurse in a mental health facility is reviewing the lab results of a client who is taking
lithium carbonate. Which of the following findings places the client at risk for lithium
toxicity?
a. Sodium 132
b. Aspartate aminotransferase 40 units/L
c. WBC 6,000/mm3
d. Calcium 10.0 mg
70. A nurse is providing teaching about relapse prevention to a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the
teaching?
a. I shouldn’t worry about the voices because they are a part of my illness
b. I should let my counselor know if i am having trouble sleeping
c. I should avoid being around others if i think I’m having a relapse
d. I should increase my carb intake to maintain my energy level