26. A nurse is caring for multiple clients on a mental health unit….

Question Answered step-by-step 26. A nurse is caring for multiple clients on a mental health unit…. 26. A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attends to first?A client who is standing in her room, yelling obscenities and throwing her clothes.A client in the dayroom who is screaming at other clients about what is on television.A client who is repeatedly approaching the nurse’s station to request medication for his anxiety.A client who has bipolar disorder and is continuously pacing at the end of the hall.27. a nurse is reviewing the plan of care for an older adult client who is oriented during the day but has   recently become confused at night, which of the following interventions should the nurse recommend to update the clients plan of care?Advise family members not to visit the client after the evening meal.Recommend a stimulating activity when the client become confused.Request a PRN prescription for an antianxiety medication.Transfer the client to a private room away from the nurse’s station.28. A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer’s disease. The caregivers reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?Encourage the client to nap during the day.Place a lock at the top of doors leading outside.Administer an antianxiety medication before bedtime.Use light restraints while the client is in bed.29. A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consents?Participating in a group exercise program.Receiving light therapy.Attending a cognitive behavior therapy class.Taking an experimental medication’30. A nurse in community health center is caring for a client who states, “my partner passed away 6 months ago. “Which of the following findings indicates a maladaptive response to grieving?The client is giving away her partner’s clothes.The client attends a grief support group.The client is unable to workThe client sleeps 6 hr per night.31.    A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse the nurse suspect’s abuse. Which of the following actions should the nurse take?Interview the child about the suspected abuse with a parent present.Inform that the findings must be reported to authorities.Complete an incident repot for risk management.Avoid asking the child what cause the injury.32. A nurse is assisting with the admission of a client who has antisocial personality disorder. The client states, You are so nice. Can I go to the hospital gift shop just one time and then answer all your questions?” which of the following responses should the nurse make?Why do you think it is necessary to flatter me to obtain this privilege?I can allow you to go quickly, but we must set a time limit.”I really appreciate your kind comment.”We need to focus on completing this task right now.”33. A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of the maturational crisis?Motor-vehicle crashDivorceLoss of jobA child is leaving for college.34. A nurse is contributing to plan care for a client who is experiencing a panic level of anxiety. Which of the following interventions should the nurse include? (Select all the apply.)Take the client to a group therapy session.Encourage the client to visit with friends.Speak to the client using a calm tone of voice.Offer to take a walk with the client.35. A nurse in an inpatient mental health facility is caring for a client who states, “I do not want anyone to know I am in a mental hospital.” Which of the following responses should the nurse make?We have to obtain your permission to discuss your care with others.We have to notify your insurance company that you are here.”We have to inform your immediate family members that you are here.We have to report your admission to the National Alliance on mental illness,36. A client who delivered a healthy newborn 4 weeks ago calls her provider’s office and tells the nurse,” This baby constantly cries. My partner works all the time, and I can’t take anymore. “Which of the following responses is the nurse’s priority?Have you discussed this with your partner?Having a newborn must be stressful. Do you have other children?”Tell me about your baby. Where is she now?Do you have a friend who could help you?37. A nurse is assisting in teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barrios to learning?Assist the client in establishing long-term goals.Ensure the teaching sessions occur right before bedtimeUse “I” statements rather than you” statements.Schedule the teaching sessions for a long time to promote participation.38. A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?The client displaces their feelings of self-harm until they talk to the provider.The client notifies the nurse when they want to harm themselves.The client goes to their room alone when they feel overwhelmed.The client suppresses their feeling when they are angry.39.  A nurse in a mental facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?PsychodramaCodependency supportDual diagnosis treatmentCrisis intervention40. A nurse is helping lead a support group for clients in a long-term care facility. Which of the following is the leader’s task during the termination phase of group development?Reflect on progress.Encourage problem solving.Discuss ground rules.Guide conflict resolution.41. A nurse is reinforcing teaching with a client who has a new prescription for clozapine. Which of the following information should the nurse include?We will test your stool for blood every 2 weeks.We will measure your iron level before you begin this prescription.”We will collect a 24 24-hour urine sample once monthly.”We will check your white blood cell count weekly.”42. A nurse is assisting with a community health education and support service for individuals who have lost loved ones to suicide. Which of the following actions should the nurse take when caring for these individuals? Refer to the deceased person as the client, not the individual.Recommend that the individual wait at least 3 months before joining support group.Wait until the individual talks about their deceased loved one before mentioning their name.Ask open-ended questions when talking to the individual about their grief.43. A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client’s voice. Which of the following interventions should the nurse implement first?Place the client in restraints.Obtain prescription for haloperidol.Take the client to the seclusion room.Verbally de-escalate the client.44. A nurse is reinforcing teaching with a client who is grieving the recent loss of their partner. Which of the following interventions should the nurse make?Use sympathy to develop a trusting relationship with the client.Encourage the client to talk about the death of their partner.Advise the client to maintain the daily routine they shared with their partner.Inform the client that the acute phase of the grief process should last at least 6 months.45. A nurse is collecting data from a bulimia nervosa. Which of the following findings should the nurse expect?HypomagnesemiaLanugoHypokalemiaMuscle wasting46. A nurse is caring for a client who was involuntarily admitted for the treatment of mania. The client asks the nurse, is it true that my doctor can force me to take medications while I’m here? which of the following response should the nurse take?You can be medicated against your wishes because you were admitted without your consent.”You are required to take medications that are prescribed to treat your mania.You should take your medications so you can go home.You can be medicated against your wishes if you are a danger to yourself or others.47. A nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infection. Which of the following findings indicates that the client is developing delirium?Pale, dry skinDecreased blood pressureDisorganized thinkingPinpoint pupils48.  A nurse is reviewing the urine drug screen report of a client who test positive for cocaine. Which of the following findings should the nurse expects?TachycardiaConstricted pupilsLethargySlurred speech49. A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?Tell the sibling the client does not want visitors.Arrange for the siblings to visit the client in the dayroom.Encourage the client to visit with the sibling.Refer the sibling to the client’s provider.50.  A nurse is caring for a client who has major depressive disorder. The client tells the nurse, I should be dead. I have been a failure. “Which of the following responses should the nurse make?You are feeling like a failure?You’re not the only client who feels this way.How can you feel that way when you have so much to live for?I see many positive things about you.51. A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. which of the following manifestations should the nurse include in the teaching? Enjoys spending time aloneExhibits extreme perfectionismUnable to make simple decisionsDisplays confrontational behavior52. A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescription for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?Documents the client’s behavior every 2 hr.Implement 24-hr one-to-one nursing observation.Administer prescribed medication vis the IM route.Restrict interactions with other clients.53.  A home health nurse is caring for a client who has Alzheimer’s disease and lives with her adult child. The child is concerned for the client’s safety because the client wandered away from home several several nights ago. Which of the following recommendations should the nurse make?Establish a place for the client to walk inside the house.Provide complex activities to exercise musclesProvide a high-stimulation environment.Encourage the client to take naps in the late afternoon.54. A nurse is reinforcing teaching with a client who is about to start taking sertraline to treat depression. Which of the following information should the nurse reinforce with the client?You can adjust your dosage depending on the level of symptoms you have.Your provider will have to monitor your blood glucose levels routinely.You have to avoid eating foods that contain tyramine, such as wine and cheese.You should avoid taking St john’s wort while taking this medication.55. A nurse in an acute care facility is assisting with the admission of a client is experiencing alcohol withdrawal. The nurse should observe the client for which of the following findings?RhinorrheaHypotensionNystagmusTachycardia56. A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following statements should the nurse plan to take?Use an overly friendly approach.Be vague when answering the client’s questions about instructions.Demonstrate a neutral demeanor.Ask the client why he is suspicious of others.57.  A nurse is collecting data from a child who takes methylphenidate. Which of the following findings indicates effective management of the medication’s adverse effects?The child’s BUN levels is 12 mg/Dl.The child has a reduced attention span.The child’s weight has increased from the previous visit.The child sleeps fewer total hours per day.58. A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?Reduction in hand tremorsDecreased hallucinations.Improved mood.Absence of seizure.59. A nurse is caring for a client who has anxiety disorder and reports ongoing difficulty sleeping at night. Which of the following recommendations should the nurse make?”Exercise 1 hour before bedtime.””Drink 5 ounces of red wine roughly 30 minutes before bed.”Limit caffeine to one or two servings during daytime hours.”Stay in bed for 1 hour before getting up if you are unable to sleep.60. A nurse is collecting data from a client who states, “I am so worried about everything, and I can’t seem to sit still, even when I eat. “Which of the following responses should the nurse make?”Why do you think this is so upsetting for you?”Can you tell me about what is worrying you?”Even though you are worried, it is important to eat maintain your strength.”It is common to be worried about some things, but you will feel better soon. 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