QUES: a 30 year old sales manager tells the nurse "i am thinking about a job change.

don't feel like i am living up to my potential." which of maslows developmental stages is the

sales manager attempting to achieve

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QUES: the nurse observes a client who is admitted to the mental health unit and identifies

that the client is talking continuously, using words that rhyme but have no context or

relationship with one topic to the next in the conversation. This clients behavior and

thought processes are consistent with which syndrome

QUES: a homeless person who is in the manic phase of bipolar disorder is admitted to the

mental health unit.. which lab finding obtained on admission is most important for the

nurse to report to the HCP

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QUES: an adult male client who was admitted to the mental health unit yesterday tells the

nurse that microchips were planted in his head for military surveillance of his every move..

which response is best for the nurse to provide

QUES: the nurse is assessing a clients intelligence.. which factor should the nurse

remember during this part of the mental status exam

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QUES: at a support meeting of parents of a teenager with polysubstance dependency, a

parent states "each time my son tries to quit taking drugs, he gets so depressed that I'm

afraid he will commit suicide".. the nurses response should be based on which information

QUES: the wife of a male client recently diagnosed with schizophrenia asks the nurse,

"what exactly is schizophrenia? is my husband all right?".. which response is best for the

nurse to provide

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QUES: a young adult male client, diagnosed with paranoid schizophrenia, believes that the

world is trying to poison him.. what intervention should the nurse include in this clients

plan of care

QUES: the community health nurse talks to a male client who has bipolar disorder.. the

client explains that he sleeps 4-5 hours a night and is working with his partner to start two

new businesses and build an empire.. the client stopped taking his meds several days ago..

what nursing problem has the highest priority

QUES: a female client with OCD is describing her obsessions and compulsions and asks the

nurse why these make her feel safer.. what information should the nurse include in this

clients teaching plan

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QUES: The nurse observes a female client with schizophrenia watching the news on TV..

she begins to laugh softly and says, "yes my love ill do it".. when the nurse questions the

client about her comment she states, "the news commentator is my lover and he speaks to

me each evening.. only i can understand what he says".. what is the best response for the

nurse to make

what do you believe the news commentator said to you:

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QUES: a 40 year old male client diagnosed with schizophrenia and alcohol dependence has

not had any visitors or phone calls since admission.. he reports he has no family that cares

about him and was living on the streets prior to this admission.. according to ericksons

theory of psychosocial development, which stage is the client in at this time

QUES: the parents of a 14 year old boy bring their son to the hospital.. he is lethargic, but

responsive.. the mother states "i think he took some of my pain pills".. during initial

assessment of the teenager, what information is most important for the nurse to obtain

from the parents

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QUES: a male client with mental illness and substance dependency tells the mental health

nurse that he has started using illegal drugs again and wants to seek treatment.. since he

has a dual diagnosis, which person is best for the nurse to refer this client to first
QUES: a male client is admitted to a mental health unit on friday afternoon and is very

upset on sunday because he has not had the opportunity to talk with the HCP.. which

response is best for the nurse to provide this client

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QUES: a female client refuses to take an oral hypoglycemic agent bc she believes that the

drug is being administered as part of an elaborate plan by the mafia to harm her.. which

nursing intervention is most important to include in this clients plan of care

QUES: a male client is admitted to the psychiatric unit with a medical diagnosis of

paranoid schizophrenia.. during the admission procedure, the client looks up and states

"no, its not my fault, you can't blame me, i didn't kill him, you did".. what action is best for

the nurse to take

QUES: an 86 year old female client with alzheimers disease is wandering the busy halls of

the extended care facility and asks the nurse "where should i stand for the parade".. which

response is best for the nurse to provide

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QUES: physical exam of a 6 year old reveals several bite marks in various locations on his

body.. x-ray exam reveals healed fractures of the ribs.. the mother tells the nurse that her

child is always having accidents.. which initial response by the nurse would be most

appropriate
QUES: a child is brought to the emergency room with a broken arm.. bc of other injuries,

the nurse suspects the child may be a victim of abuse.. when the nurse tries to give the child

an injection, the childs mother becomes very loud and shouts "i won't leave my son! don't

you touch him! you'll hurt my child!".. what is the best interpretation of the mothers

statements.. the mother is

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QUES: a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia..

when her tray is brought to her, she refuses to eat and tells the nurse, "i know you are

trying to poison me with that food".. which response is most appropriate for the nurse to

make

QUES: a 25 year old female client has been particularly restless and the nurse finds her

trying to leave the psychiatric unit.. she tells the nurse "please let me go! i must leave bc the

secret police are after me".. which response is best for the nurse to make

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QUES: a 45 year old male client tells the nurse that he used to believe that he was jesus

christ, but now he knows he is not.. which response is best for the nurse to make

QUES: a nurse working in the emergency room of a children's hospital admits a child

whose injuries could have resulted from abuse.. which statement most accurately describes

the nurses responsibility in cases of suspected child abuse

QUES: a client who is being treated with lithium carbonate for bipolar disorder develops

diarrhea, vomiting, and drowsiness.. what action should the nurse take

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QUES: a client on the psychiatric unit appears to imitate a certain nurse on the unit.. the

client seeks out this particular nurse and imitates her mannerisms.. the nurse knows that

the client is using which defense mechanism

QUES: a client, who is on a 30 day commitment to a drug rehabilitation unit, asks the

nurse if he can go for a walk on the grounds of the treatment center.. when he is told that

his privileges do not include walking on the grounds, the client becomes verbally abusive..

which approach should the nurse use

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QUES: the nurse is planning the care for a 32 year old male client with acute depression..

which nursing intervention best helps this client deal with his depression

QUES: an anxious client expressing a fear of people and open places is admitted to the

psychiatric unit.. what is the most effective way for the nurse to assist this client

QUES: a client with bipolar disorder on the mental health unit becomes loud, and shouts at

one of the nurses "you fat tub of lard! get something done around here!".. what is the best

initial action for the nurse to take

QUES: a 35 year old male client who has been hospitalized for two weeks for chronic

paranoia continues to state that someone is trying to steal his clothing.. which action should

the nurse implement

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QUES: on admission, a highly anxious client is described as delusional.. the nurse

understands that delusions are most likely to occur with which class of disorder

QUES: a client is admitted with a diagnosis of depression.. the nurse knows that which

characteristic is most indicative of depression

QUES:a 45 year old female client is admitted to the psychiatric unit for evaluation.. her

husband states that she has been reluctant to leave home for the last six months.. the client

has not gone to work for a month and has been terminated from her job.. she has not left

the house since that time.. this client is displaying symptoms of what condition

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QUES: a client who has been admitted to the psychiatric unit tells the nurse "my problems

are so bad that no one can help me".. which response is best for the nurse to make

QUES: a woman brings her 48 year old husband to the outpatient psychiatric unit and

describes his behavior to the admitting nurse.. she states that he has been sleepwalking,

cannot remember who he is, and exhibits multiple personalities.. the nurse knows that

these behaviors are often associated with

QUES: a 27 year old female client is admitted to the psychiatric hospital with a diagnosis of

bipolar disorder, manic phase.. she is demanding and active.. which intervention should the

nurse include in this clients plan of care

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QUES: the nurse plans to help an 18 year old female mentally retarded client ambulate the

first postoperative day after an appendectomy.. when the nurse tells the client it is time to

get out of bed, the client becomes angry and tells the nurse "get out of here! ill get up when

I'm ready!".. which response is best for the nurse to make

QUES: a 46 year old female client has been on antipsychotic neuroleptics for the past three

days.. she has had a decrease in psychotic behavior and appears to be responding well to

the medication.. on the fourth day, the clients blood pressure increases, she becomes pale

and febrile, and demonstrates muscular rigidity.. which action should the nurse initiate

QUES: a 35 year old male client on the psychiatric ward of a general hospital believes that

someone is trying to poison him.. the nurse understands that a clients delusions are most

likely related to his

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QUES: a client who is diagnosed with schizophrenia is admitted to the hospital.. the nurse

assesses the clients mental status.. which assessment finding is most characteristic of a

client with schizophrenia

QUES: the nurse is conducting discharge teaching for a client with schizophrenia who

plans to live in a group home.. which statement is most indicative of the need for careful

follow up after discharge

QUES: a 52 year old male client in the ICU who has been oriented suddenly becomes

disoriented and fearful.. assessment of VS and other physical parameters reveal no

significant change and the nurse formulates the diagnosis "confusion related to ICU

psychosis".. which intervention is best to implement

QUES: a 19 year old female client with a diagnosis of anorexia nervosa wants to help serve

dinner trays to other clients on a psychiatric unit.. what action should the nurse take

QUES: a male client with schizophrenia who is taking fluphenazine decanoate (prolixin

decanoate) is being discharged in the morning.. a repeat dose of medication is scheduled for

20 days after discharge.. the client tells the nurse that he is going on vacation in the

bahamas and will return in 18 days.. which statement by the client indicates a need for

health teaching

when i return from my tropical island vacation,

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QUES: the nurse is leading a "current evens group" with chronic psychiatric clients.. one

group member states "clara barton was my nurse during my last hospitalization.. she was a

very mean nurse and wasn't nice to me".. which response is best for the nurse to make
QUES: an adult client with a medical diagnosis of substance abuse and schizophrenia was

recently switched from oral fluphenazine HCl to IM fluphenazine decanoate.. what is most

important to teach the client and family about this change in medication regimen

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QUES: the nurse should hold the next scheduled dose of a clients haloperidol (Haldol)

based on which assessment finding

QUES: within several days of hospitalization, a client is repeatedly washing the top of the

same table.. which intervention is best for the nurse to implement to help the client cope

with anxiety related to this behavior

QUES: a female client with depression attends group and states that she sometimes misses

her medication appointments bc she feels very anxious about riding the bus.. which

statement is the nurses best response

what are some ways that you can cope with your anxiety:

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QUES: a nurse working on a mental health unit receives a community call from a person

who is tearful and states "i just feel so nervous all of the time.. i don't know what to do

about my problems.. i havent been able to sleep at night and have hardly eaten for the past

3-4 days".. the nurse should initiate a referral based on which assessment
QUES: the nurse is planning discharge for a male client with schizophrenia.. the client

insists that he is returning to his apartment, although the HCP informed him that he will

be moving to a boarding home.. what is the most important nursing diagnosis for discharge

planning

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QUES: a male client is admitted to the mental health unit bc he was feeling depressed

about the loss of his wife and job.. the client has a history of alcohol dependency and admits

that he was drinking alcohol 12 hours ago.. VS are T 100, P 100, BP 142/100.. the nurse

plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis

QUES: when preparing a teaching plan for a client who is to be discharged with a

prescription for lithium carbonate (Lithonate), it is most important for the nurse to include

which instruction

QUES: the nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the

psychiatric unit.. which complaint related to administration of this drug should the nurse

expect this client to make

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QUES: a client is receiving substitution therapy during withdrawal from benzodiazepines..

which expected outcome statement has the highest priority when planning nursing care
QUES: a client who is known to abuse drugs is admitted to the psychiatric unit.. which

medication should the nurse anticipate administering to a client who is exhibiting

benzodiazepine withdrawal symptoms

QUES: a 22 year old male client is admitted to the emergency center following a suicide

attempt.. his records reveal that this is his third suicide attempt in the past two years.. he is

conscious, but does not respond to verbal commands for treatment.. which assessment

finding should prompt the nurse to prepare the client for gastric lavage

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QUES: a 72 year old female client is admitted to the psychiatric unit with a diagnosis of

major depression.. which statement by the client should be of greatest concern to the nurse

and require further assessment

QUES: which diet selection by a client who is depressed and taking the MAOI

tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the

dietary restrictions imposed by this medication regimen

QUES: the nurse is planning care for a 32 year old male client diagnosed with HIV

infection who has a history of chronic depression.. recently, the clients viral load has begun

to increase rather than decrease despite his adherence to the HIV drug regimen.. what

should the nurse do first while taking the clients history upon admission to the hospital

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QUES: a 65 year old female client complains to the nurse that recently she has been

hearing voices.. what question should the nurse ask this client first

QUES: on admission to a residential care facility, an elderly female client tells the nurse

that she enjoys cooking, quilting, and watching television.. twenty four hours after

admission, the nurse notes that the client is withdrawn and isolated.. it is best for the nurse

to encourage this client to become involved in which activity

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QUES: an elderly female client with advanced dementia is admitted to the hospital with a

fractured hip.. the client repeatedly tells the staff "take me home.. i want my mommy"..

which response is best for the nurse to provide

QUES: the nurse suspects child abuse when assessing a 3 year old boy and noticing several

small, round burns on his legs and trunk that might be the result of cigarette burns.. which

parental behavior provides the greatest validation for such suspicions

QUES: a male adolescent is admitted with bipolar disorder after being released from jail

for assault with a deadly weapon.. when the nurse asks the teen to identify his reason for

the assault, he replies "bc he made me mad!".. which goal is best for the nurse to include in

the clients plan of care.

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QUES: the nurse should include which interventions in the plan of care for a severely

depressed client with neurovegetative symptoms

QUES: the psychiatric nursing client may be an individual, family, group, organization, or

community:

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QUES: the charge nurse is collaborating with the nursing staff about the plan of care for a

client who is very depressed.. what is the most important intervention to implement during

the first 48 hours after the clients admission to the unit

QUES: at the first meeting of a group of older adults at a day care center for the elderly,

the nurse asks one of the members what kinds of things she would like to do with the

group.. the older woman shrugs her shoulders and says "you tell me, you're the leader"..

what is the best response for the nurse to make

QUES: over a period of several weeks, one male participant of a socialization group at a

community day care center for the elderly monopolizes most of the groups time and

interrupts others when they are talking.. what is the best action for the nurse to take in this

situation

QUES: the nurse is taking a history for a female client who is requesting a routine female

exam.. which assessment finding requires follow up

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QUES: The nurse is assessing the parents of a nuclear family who are attending a support

group for parents of adolescents.. according to erickson, these parents who are adapting to

middle adulthood should exhibit which characteristic

QUES: a male client with schizophrenia tells the nurse that the voices he hears are saying

"you must kill yourself".. to assist the client in coping with these thoughts, which response

is best for the nurse to provide

QUES: a woman arrives in the emergency center and tells the nurse she thinks she has

been raped.. the client is sobbing and expresses disbelief that a rape could happen bc the

man is her best friend.. after acknowledging the clients fear and anxiety, how should the

nurse respond

QUES: a woman admitted to the ED is bleeding profusely from a patch where hair was lost

from her scalp.. she is accompanied by her husband who tells the nurse that his wife caught

her hair on the railing and pulled it out when she fell down the stairs.. the husband is

solicitous of his wife and quickly answers questions on her behalf.. he attempts to comfort

his wife by saying to her "i am right here with you dear, nothing can keep us apart".. what

is the priority nursing intervention

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QUES: while assessing a 70 year old male client, a nurse working in the outpatient clinic

notices bruises on the clients chest.. the client admits that his daughter, who is is caregiver,

becomes frustrated and sometimes hits him.. what is the priority outcome for the elderly

client who sustained the abuse

QUES: the nurse is assessing a client who is believed to have a borderline personality

disorder.. which question is most important to include in this assessment

QUES: a nurse is teaching a female client who is in a homosexual relationship about

womens health.. which topic is the most important for the nurse to address

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QUES: 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

QUES: a male client who is on the liver transplant list is called to the unit for a possible

transplant.. when learning that the donor organ is no longer available, the client slams

doors and shouts vulgarities about his situation.. what action should the nurse implement

first

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QUES: a client is told that her infant will be stillborn.. what is the most important action

for the nurse to implement after the birth

QUES: a client who has a miscarriage at 10 weeks gestation tells the nurse that she already

purchased some baby things and picked out a name.. after the surgical dilation and

curettage, the client wants to go home as soon as possible.. based on the clients statements,

which action should the nurse implement

QUES: which nursing intervention should the nurse implement with parents who

experience a fetal demise and express the wish not to see the baby
QUES: a client actively involved in substance addiction therapy frequently relapses into

benzodiazepines and alcohol use.. the client tells the nurse, i don't think i will ever be able

to kick this habit.. how should the nurse respond

QUES: a client who is admitted with the chief complaint of feeling depressed tells the

nurse, i want to feel normal agiain.. how should the nurse respond

QUES: the nurse is planning the care for a client based on the psychoanalytical model..

which intervention should the nurse include

QUES: a female client responds to the nurse with negative comments and antagonistic

behavior.. the nurse tells the client that she is unconsciously casting the nurse in the role of

the clients mother.. the nurses feedback is based on which model of therapy

QUES: which client should the nurse identify as the highest risk for the onset of stress

related problems

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QUES: 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

QUES: 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

QUES: a client with panic disorder tells the nurse, "this illness is awful, I'm frightened that

i will always be this way and that theres no hope for me".. what is the best information for

the nurse to provide

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QUES: a female client who is admitted for treatment of uncontrolled DM is withdrawn and

tearful.. she complains she has gained excessive weight bc she hates her diet, hates taking

insulin, and just wants to be normal again.. what therapeutic action should the nurse take

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QUES: 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

QUES: when assessing a clients emotional intelligence, which client capabilities should the

nurse focus the interview on with a client diagnosed with a chronic mental illness

QUES: a female client with severe depression is given information about risks, benefits,

alternatives, and expected outcomes of ECT and signs the informed consent for treatment..

after the clients family leaves, the client tells the nurse, i signed the papers bc my husband

told me i will be deported if my depression is not cured.. what information should the nurse

report to the HCP

QUES: a male client tells the nurse that he plans to kill his spouse and her lover as soon as

he is released from the hospital.. what action should the nurse implement

QUES: a male client is brought to the emergency department by a police officer, who

reports the client was disturbing the peace by running naked in the street, striking out at

others, and smashing care windows.. which behaviors should the client demonstrate to

determine if he should be evaluated for involuntary commitment

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QUES: what action should the nurse take when a client who is psychotic proposes goals

that are both unrealistic and undesirable

QUES: a client is pacing in the hall near the nurses station and swearing loudly.. what

response is best for the nurse to provide

QUES: a client is responding to auditory hallucinations and shakes a fist at a nurse and

says "back off witch!".. the nurse follows the client into the day room.. what action should

the nurse implement

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QUES: 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! your so stupid that you'll make it worse!"..

which intervention is best for the nurse to implement

QUES: a 35 year old married woman works full time in a factory and 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 is most important for the nurse to initially use

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QUES: a female client presents to the emergency center with confusion, 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.. what action should

the nurse implement first

QUES: which client outcome indicates improvement for a client who is admitted with

auditory hallucinations

QUES: the nurse is caring for an adult male client with catatonic schizophrenia who is

mute and motionless.. what is the priority nursing diagnosis

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Ques: a client with a history of alcoholism with a compound fracture of the femur after

falling down the previous night.. what additional assessment should be the priority focus

for the nurse

QUES: 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?

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QUES: a female client comes to an outpatient therapy appointment intoxicated.. the spouse

tells the nurse, "there wasn't anything i could do to stop her drinking this morning".. what

intervention should the nurse take at this time

QUES: which client statement should the nurse identify as most typical of a client with

mania

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QUES: what nursing assessment is the priority focus for a client with major depression

QUES: the nurse is caring for a client who received the first time ECT a half hour ago..

which action should the nurse implement first

QUES: a client with substance abuse is admitted to the mental health unit.. which action

should be implemented by the nurse, and not delegated to a UAP

QUES: which action should the nurse implement first for a client experiencing alcohol

withdrawal

QUES: 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 HCP

QUES: during a one to one interaction, a male client describes the sadness he experienced

when his mother died.. suddenly, the nurse begins to think about her grandmothers death..

as a result, the nurse asked the client to describe his thoughts when he learned of his own

mothers illness.. what is the nurse doing

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QUES: the community health nurse facilitates a substance abuse prevention group for a

homeless population.. which statement demonstrates that a client has a realistic

understanding of the recovery process?

QUES: a female client with bipolar disorder, manic phase, is planning weekend activities

with the other clients on the unit.. the client interrupts the group, insists that they change

their plans to a disco party, and begins to curse loudly when the group refuses to change

the plans.. which intervention should the nurse implement

QUES: which action should the nurse implement during the termination phase of the nurse

client relationship?
QUES: which statement made by an adolescent in group therapy should the nurse identify

as a priority in planning care?

QUES: 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

QUES: 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

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QUES: an adolescent who attempted suicide with drug OD arrives in the ED with an empty

30 tab bottle of acetaminophen.. which action should the nurse implement

QUES: a client on the mental health unit reports concerns about weight gain as a result of

taking divalproex (Depakote) and requests assistance to fill out a menu.. the nurse should

initiate a referral to which health care team

QUES: during the admission of a male client to the mental health unit, the client tells the

nurse that he had a panic attack today and ran out of the physicians office.. which question

is most important for the nurse to ask the client

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QUES: the daughter of a female client with stage 1 alzehimers disease asks the nurse what

changes should she expect to demonstrate in this stage.. what finding should the nurse tell

the daughter is common?