1. a nurse is caring for a client who has been placed in restrains. Which of the following actions should the nurse take?

Question Answered step-by-step 1. a nurse is caring for a client who has been placed in restrains.Which of the following actions should the nurse take? a. observe the client’s behavior one every 15 minsb. request a PRN client prescription for restainrs from the providerc. document the cleint’s behavior hourly on a flow- sheetd. remove the restraint when the client calmly follows commands2. a nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instruct the client to avoid foods with tyramine to prevent which of the following?a. hypertensive crisisb. cardiac toxicityc. urinary retentiond. serotonin syndrome3. a nurse is assessing a client who has bipolar disorder and is transitioning from hypomania to mania. Which of the following findings should the nurse expect? a. angerb. withdrawlc. anhedoniad. flat affect 4. a nurse is assessing the boundaries of a client’s family. One of the family members says to the client. I know excalty what your thinking right now. The urse should recognize that the family member is displaying which of the following types of family boundaries ?a. enmeshed b. rigidc. inconsistentd. clear 5. a nurse is assessing a client who has a family history of Alzheimer’s disease. The nurse should identify which of the following findings as an additional risk factor for dementia? a. head injury b. asthmac. hypoglycemiad. recurrent urinary tract infections 6. a nurse is assessing a client who is taking chlorpromazine. The client’s dosage was descreased 3 months ago to reduce adverse effects. Which of the following findings should the nurse identify as an indication that the reduce dosage of chlorpromazine is effective? a. increased heart rateb. improved gaitc. decreased salvationd. decreased ringing in the ears 7. a nurse is interviewing a client who was recently sexually assaulted . the client cannot recall the attack. The nurse should identify that the client is using which of the following defense mechanism?a. regressionb. reacting formationc. sublimationd. suppression 8. a nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse’s neighbor. The nurse should identify that which of the following must occur when establishing a therapeutic nurse- client relationship? a. the client sees the nurse as an authority figureb. the nurse maintains confidentiality unless the cleint’s safety is compromised. c. the client regards the nurse a s friend. d. the nurse seeks to speed extra time specifically with the client each day9. a nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take? a. explain to the client that that duration of grief Is highly variable and can last for yearsb. encourage the client to avoid discussing the events surrounding the sibiling’s deathc. caution the client against feeling angry at the sibilingd. recommend that the client participate in more solitary activites.10. a nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse plan to administer? a. clozapinebupropionc.Lorazepamd. methadone 11. a nurse is teaching the family of a client who has Alzheimer’s disease about safety interventions for night time wandering. Which of the following interventions should the nurse include? a. encourage the client to take naps during the day.b. place the client’s mattress on the floor c. place rubber- backed throw rugs on the floorsd. install locks at the bottom of the exit doors12. a nurse is assessing a client during a follow up visit at a behavioral health clinic. The client reports that they have ot been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medications adherence? a. discusses the provider’s goals for the clients careb. tell the client they will be admitted to an inpatient care facility if they do not take the medication c. request the provider prescribes a second antipsychotic mediation to the client d. ask the client if the medication is causing adverse effects13.  A nurse in an acute care mental health facility is receiving morning report for a group of clients. Which of the following clients should the nurse plan to assess first?a.  A client who has generalized anxiety disorder and reports being frightened about an upcoming dental appointment b.  A client who has recently admitted, has severe negative manifestations of schizophrenia, and is refusing to get up for breakfast c. A client who has posttraumatic stress disorder and is reported to have experienced a flashback during the night d. A client who is depressed and occasionally expresses suicidal thoughts but whose mood reported to have improved this morning14. Nurse is planning emergency care for a client who has major depressive disorder and serotonin syndrome. Which of the following actions should the nurse plan to take?a)     Prepare to administer atropine for a low heart rateb)     Administer naloxone to reverse respiratory depressionc)     Use a tepid water bath to lower body temperatured)     Place the client in a prone position to prevent dizziness15. a nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner 6 months ago. Which of following actions should the nurse take? a. discourage the client from receiving the events surrounding her lossb. suggest that the client avoid social interactions that remind her of her partnerc. direct the client to maintain an unstrucuted daily routined. explain that it can take a year or more to learn to live with a loss16. a nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the following findings indicates the client is at an increased risk for suicide? a. hypersomniab. increased energyc. psychomotor retardation d. unkempt appearance 17. A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection?a)     Can you tell me what is happening now?b)     I would like to sit with you for a whilec)     Let’s work together to try to solve your problemd)     You feel upset when this happens18. a nurse is caring for a client who recently experienced the unexpected death of his child. Which of the following actions should the nurse take first? a. initiates a referral for the client to receive individual counselingb. ask the client if he is thinking about self- harm c. identify the client’s support system d. request a prescription for alprazolam for the client Health Science Science Nursing NURS 2488 Share QuestionEmailCopy link Comments (0)