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Question Answered step-by-step Which would the nurse determine is the priority action before… Which would the nurse determine is the priority action before initiating an intermittent enteral feeding? 1.Weighing the client2.Determining tube placement3.Checking intake and output records4.Obtaining an abdominal x-ray Health Science Science Nursing NURSING 203 Share QuestionEmailCopy link Comments (0)

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QuestionAnswered step-by-step.A client diagnosed with major depressive disorder is considering cognitive behavioral therapy. The client asks the nurse if this therapy would alleviate depressive thoughts. What is the best response by the nurse?"The purpose of this therapy is to determine how to get psychological needs met through interpersonal relationships.""In this therapy, you will explore past events and analyze how these events have affected your behavior and thoughts.""This therapy helps you learn to think more positively, and thereby reduce depressive thoughts and symptoms.""This type focuses on how you use defense mechanisms to feel more comfortable and content."2. The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor the use of a clinical opioid withdrawal screening Tool (cows). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizuresHeightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks Diaphoresis, piloerection, tremors, irritability. Insomnia, nausea, and vomiting.Cravings, Depression, fatigue, hypersomnolence, and impaired judgment.3. A nurse is preparing to administer fluoxetine 80 mg PO daily. Available is fluoxetine 40 mg/5mL. How many ML should the nurse administer per dose?  10ML 4. Which statement by the client indicates an understanding of the nurse's teaching regarding antipsychotic medication? ( select all that apply.)"I can become addicted to these medications"."One day, I won't have to take these medications.""These drugs may cause me to gain weight.""My symptoms may return if I don't take these medications.""These medications may cause negative side-effects."5. What is a SMART short-term goal for a client diagnosed with Alzheimer's disease who has lost 5 pounds in the last month?The client will eat more at each meal.The client will eat 25% of each meal for the next 24 hours.The client will increase oral intake at every meal.The client will eat higher caloric foods with each meal.6. Which of the following is the most therapeutic response by the nurse when a client states. "I no longer need my medication since I do not hear voices."?What happened the last time you stopped taking your medication?""Why don't you discuss that with your physician?""The physician prescribed that medication to help you.""I would rather you reconsider that decision.'7. A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells. "I have to AAleave and get to my barber. I see him every Wednesday. Let me out!" Which of the following would be the most therapeutic response by the nurse?"You need to come and take a shower before you can go get your haircut.""The door is locked so that you don't leave and get hurt.""Please stop banging on the door. Your room is right over there.""You are in the hospital, and I'm your nurse."8. A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?"Are you having any liver problems?""What time was your last drink?""How long have you had a problem with alcohol?""Are you experiencing a relapse?" 9. The client was prescribed phenelzine and is on a tyramine-free diet. What foods cannot be eaten? (select all that apply)Smoked turkey and beansPlain ground beef patty with an appleA pepperoni and cheese pizzaA banana and iced coffeeChicken and mashed potatoes10. A newly admitted client has a diagnosis of schizoaffective disorder. Based on this diagnosis, the nurse would expect to find which of the following symptoms?Bizarre mannerisms and hostility Waxy flexibility and catatonic excitement Agitation and ideas of reference Delusional thinking and mood changes11. During the admission interview for a client with schizophrenia the nurse asks the client "tell me the names of the medication you are currently taking." The client responds, "medications, abbreviations, deviations, medications," The nurse will document which form of speech pattern the client is demonstrating?Pressured speech Neologism EcholaliaClang association12. A female client is experiencing delusions of grandeur and is highly suspicious of others. What is the most therapeutic approach to use?Provide an activity in which she can excelUse the "approving" communication techniqueRecognize her feelings and assure her that she is safe.Reassure her and let her know others care.13. A client states. "My life doesn't have any happiness in it anymore. I once enjoyed going out with friends, but now I don't care if they even invite me. "Which term best describes the client's feelings?Anergia-a chronic state of lethargy and low energyAffect -outward expression of a person's internal emotions.example if u told someone has died  reaction would be sadness and fearAnhedoniaAgnosia14. What client population is at risk of developing tardive dyskinesia?Clients who have received long-term neuroleptic treatment.Clients who have experienced neuroleptic malignant syndrome (NMS).Clients who have discontinued their neuroleptic treatment.Clients who have received monoamine oxidase inhibitors (MAOIs).15. A client diagnosed with schizophrenia begins to talk about "crackers" in the local shopping mall. The word "crackers" should be documented as which term?Concrete thinking Thought insertion NeologismAn idea of reference16. 17.18. A student nurse prepares to administer oral medication to a client with major depression but the client refuses the medication. The student nurse should do which of the following?Tell the client, "I'll get an unsatisfactory grade if I don't give you the medication".Document the client's refusal of the medication without further comment.Tell the client, "Refusing your medication is not permitted. You are required to take it."Explore the client's concerns about the medication, and report to the staff nurse.19. The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?Teach aggressive communication skills.Provide activities that can be accomplishedSet limits on manipulative behaviors.Encourage description of perceived failures.20. Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication.The client has extrapyramidal symptoms (EPS).The client has increasing aggression.The client has complaints of dizziness.The client has elevated blood pressure.21. What statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?As depression lifts, physical energy becomes available to carry out suicide.Suicidal clients have difficulty using social support.Suicide may be precipitated by a variety of internal and external events.Suicide is an impulsive act that has no warning.22. After assessing a client and determining the impact of his alcohol addiction on the family members, the nurse suggests family therapy. The client's spouse states. I don't need to attend. I'm not an alcoholic. I don't need to attend. I'm not an alcoholic. I do not have a problem. "What is the nurse's best response?"Your lifestyle can change by this diagnosis"."No one said you were an alcoholic.""It is important that all family members who could be impacted are present.""You should want to help your spouse in any way you can."23. A client with depression is taking a tricyclic antidepressant. The client says."I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up. What action by the nurse is best?Tell the client that the side effects are a minor inconvenience compared to the feelings of depression.Withhold the drugs, forcing oral fluids, and notify the health care provider to examine the client.Update the client's mental status examination.Explain how to manage hypotension and educate the client that side effects go away after several weeks.24. A nurse is caring for a client who exhibits manifestations of major depressive disorder. The provider wants to rule out any other medical conditions that may be contributing to or causing the symptoms. Which diagnostic test should the nurse expect to be ordered?Kidney function test Thyroid panel (TSH, T3, T4)Liver function test Urinalysis with culture 25. A client diagnosed with bipolar I disorder is in a manic state, rushing about the unit, and talking regularly with a fight for ideas. What is the most therapeutic intervention?Encourage the client to talk more so you can determine what he is thinkingPolitely ask the client to stop talking Speak slowly and in a quiet voice to help the client focus Have the client go to his room until calm26.  A client is admitted with tachycardia, hypertension, restlessness,agitation, and admits substance use. Which substance would be most likely to cause these symptoms?An inhalant, such as paint fumesA depressant, such as alcoholAn opioid, such as meperidine A stimulant, such as cocaine27. A nurse is providing teaching to a client with a new prescription for a monoamine oxidase inhibitor (MAOI). When the client creates a sample lunch menu. Which item selected indicates the need for further education?Carrot sticksGlass of skim milk Sliced peachesPepperoni pizza28. A nurse is preparing to administer clozapine 100 mg PO daily. Available is clozapine 50 mg orally disintegrating tablets. How many tablets should the nurse administer per dose? 2 29. The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?Administer thiamine intramuscular (IM)Place the client on continuous observationExplain milieu therapy Assist the client with personal hygiene needs30. A client diagnosed with schizophrenia is experiencing delusions of persecution. How would the client express feeling persecuted?The client believes the president of the United States is his brother.The client believes the message from the television is that he is "a burden to everyone."The client believes the voice he hears is telling him to hurt someone.The client believes the Central Intelligence Agency (ICA) is hunting for him to destroy him.31. In educating the family, what would the nurse teach regarding the negative symptoms of schizophrenia?"These symptoms are temporary and will resolve in 3-6 months.""Negative symptoms reflect an excess of normal functioning.""These symptoms should not be confused with laziness.""These symptoms are under the control of the client."32. A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication?"I need to be aware of situations that may cause dehydration.""Lab work is only needed at the start of taking the medication.""There is a chance I may become addicted to this medication.""Once I feel better, I will not need to take this medication anymore."33. A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?Provide soft lighting around the clock and keep the radio on continuously.Have the client sit by the nurse's desk while awake in a room with the television on.Provide a well-lit room without glasses or shadows with minimal noise.Keep bright lights on in the room continuously and awaken the client hourly to check the mental status.34.  A nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?Request help from other medical staff.Check to see what medication the client is taking.Assess the client more thoroughly and immediately report any concerns to the provider. Encourage the client to eat more slowly.35. A client with schizophrenia reports auditory hallucinations telling her she "is a terrible person." "a loser for having schizophrenia;" and "she will never have a successful life". Does the nurse understand which of the following is the priority concern?Ineffective coping is related to the inability to manage hallucinations Impaired social interaction related to hallucination patternsLow self-esteem related to negative thought processesRisk for self-harm related to poor self-image36. The nurse is caring for a client diagnosed with premenstrual dysphoric disorder. What is the primary manifestation of this disorder?Emotional lability Loss of appetiteAnxiety insomnia37. A client with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the client?Offering to taste each portion on the tray for the client.Allowing the client to phone a local restaurant to deliver meals Providing tube feedings or total parenteral nutrition Allowing the client supervised access to food vending machines38. Which statement made by the nurse would be most appropriate to an elderly client who is confused, has no history of dementia, and is hospitalized for an acute urinary tract infection?"You are likely to become progressively more confused now.""Things may be upsetting and confusing right now, but your confusion should clear as you get better.""Don't worry about it, everyone is confused when they are in the hospital.""This is only a temporary situation."39. A client receiving risperidone reports severe muscle stiffness at 1030.    By 1200, the client has difficulty swallowing food and is drooling. The client is diaphoretic.   By 1600, vital signs are as follows: Temperature 102.8 F: pulse 110 beats/minute, reparation 26 breath/minute, and blood pressure 150/90 mmHgWhat are the nurse's best analyses and actions?Cholestatic jaundice; being a high-protein, high-cholesterol diet.Tardive dyskinesia; withhold the next dose of medication Agranulocytosis; institute reverse isolationNeuroleptic malignant syndrome; notify health care provider state40. A client with schizophrenia has begun a new prescription of clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects?Liver function studiesRed blood cell count Kidney function studies White blood cell count41. Which assessment finding by the nurse would indicate the client diagnosed with schizophrenia is not tolerating the stimulation on the unit?Increase in demands for attention Creating a disorganized project in the art group.An increase in pacing and hallucinations.Using confabulation when asked a question.42. The nurse is teaching a client about electroconvulsive therapy (ECT. which instruction is correct?You may experience recent memory loss after the treatment.You will be on bed rest immediately after your treatment. Once your gag reflex has returned, you will have a light meal.You can expect three treatments in the first two weeks.43. A client is hospitalized following a suicide attempt after breaking up with her significant other. The client said to the nurse," When do I get out of here, I'm going to try this again, and next time I'll get it right!" Which is the best response by the nurse?"What exactly do you plan to do?""You are safe here. We will make sure nothing happens to you.""I don't understand. You have so much to live for.""You're just lucky your roommate came home to help you when she did."44. The nurse states in the report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving the report expect to observe?Hallucinations and delusionsFlat affect and hygiene needsWithdrawal and avolitionSocial isolation and anhedonia45. A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?"I can't worry about that problem right now.""I have to drink to relax for today's treatment.""Why does it matter to you if I drink?""I have not drunk anything in the last day."46. A college student became severely depressed after failing two examinations. The student cried for 2 hours, then tried to phone their parents but got no answer. The student then gave several expensive sweaters to a roommate. Later, the student was found unconscious on the floor with an empty pill bottle nearby. Which behavior provides the strongest clue of an impending suicide attempt?Giving away sweatersStaying alone in a dorm roomCalling parentsExcessive crying47. While caring for a client in a manic phase of bipolar disorder, the client has rapid-pressured speech and demonstrates a flight of ideas. Which of the following would be the best response for the nurse to make?"I'm having a hard time following your train of thoughts.""You are all over the place. Please pick a single topic.""It's clear you have not been taking your medications.""No one can understand you when you speak that fast."48. A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?An idea of referenceA delusion of infidelity EcholaliaAn auditory hallucination 49. A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response by the nurse?"Gradual downward tapering off this drug is necessary.""A planned reduction is not necessary.""The reduction process is very short.""This depends on the frequency of usage only."50. A client is showing early signs of dementia. The client's spouse asks, "What may I expect next?" What is the nurse's best response?"He may not recognize you and other people who have been in his life.""He may begin to try to recover recognition of his memory loss by creating events.""He may have difficulty with motor skills such as walking.""The inability to communicate with speech comes immediately after the early signs."51. An 82-year-old client is diagnosed with Alzheimer's disease ( stage 7). The client's daughter states, "No one told me my dad would be unable to talk to me." What relevant information should the nurse include in her response to this comment?"The ability to recognize objects decreases as the disease progresses.""Communication decreases as the disease progresses.""Clients have an inability to feed themselves as the disease progresses.""Loss of muscle coordination decreases as the disease progresses."52. The nurse receives reports on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality. "What intervention is most therapeutic when caring for this client?Use the communication technique of reflecting.Redirect the conversation to assist him in focusing on the topic.Allow him to continue the conversation at his own pace.Stop him and tell him how his conversation sounds to others.53. What intervention is a priority when the client is experiencing auditory hallucinations?Determine what precipitates these hallucinations.Determine the content of the hallucinations.Distract the client when having hallucinations.Let the client know you do hear the voices.54. A nurse is teaching a group of clients regarding the use of naltrexone in treating alcoholism. What would the nurse teach about the effectiveness of this drug?It reduces the craving for alcohol.It treats depressive symptoms.It is useful in managing heightened anxiety.It prevents withdrawal symptoms.55. A client experiencing delirium states to the nurse. "I see headless people walking down the hall at night." Which nursing response is the most appropriate?"Let's think about this. A headless person would not be able to walk down the hall.""It must be frightening. I realize this is real to you, but I do not see headless people."" What makes you think there are headless people here?""I don't see those people you are talking about."56. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention be at this time?Placing the client on one-on-one observation while monitoring for suicidal ideations.Completing a room search to ensure there are no harmful objects available to the client.Conducting 15-minute checks to ensure safetyEncourage the client to verbalize feelings related to suicide57. An adolescent tells the school nurse. "My friend threatened to take an overdose of pills. "The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?"Have you been taking drugs and alcohol?""Do you have access to medications?""Why do you want to kill yourself?""Did something happen to your parents?"58. The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at the clients. What is the priority action of the nurse?Attempt to de-escalate the client.Continue to observe the client for increased agitation.Offer medication to help the client control behavior.Ensure safety in the environment for the client and others.59. A 29-year-old female client has recently been diagnosed with bipolar disorder and has been prescribed valproic acid. What teaching must be provided to the client regarding the medication?Every month, you will need to be weighed.""There is a chance of developing a dependency on the medication.""You will need to monitor your sodium intake while on medication.""You will need to ensure you are using a form of birth control when sexually active."60. A newly admitted client with schizophrenia approaches the unit nurse and says. The voice is bothering me. They are yelling and telling me I am bad. I have got to get away from them. Which of the following would be the most helpful reply by the nurse?Forget the voice and ask some other clients to play cards with youDo you have a plan for getting away from the voices?Do you hear the voice often?It's usual that the health care provider hasn't already stopped your medication61. During the maintenance phase of treatment, a client with biller disorder asks the nurse. Do I have to keep taking this lithium even though my mood is stable now? Which is the most appropriate response?Usually, clients take medication for approximately 6 months after dischargeTaking the medication every day helps prevent relapses and recurrencesYou will be able to stop the medication in about 1 monthIt's unusual that the health care provider hasn't already stopped your medication62. The nurse is teaching about obstacles to maintaining recovery. Which of the following statements would indicate to the nurse a greater risk for relapse? (Select all that apply) I don't know how I am going to get through this but will take it one day at a time with my family I know I am an addict, and it will take hard work and higher power to help me I will start alcoholic anonymous meetings in two weeks when I am settled after dischargeI am not going to let my family and friends know I have an addiction and give them this burden I don't know a problem, I can quit when, where and how I want to 63. The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?The client is smiling and happy with their current lifestyle The client is euphoric with excessive energy The client can accomplish all activities of daily living The client has been experiencing hallucinations and delusions for less than six months64. What are the possible physiological changes in the brain of a client diagnosed with Alzheimer's disease? (Select all that apply)Enlarged cerebral cortexAn overabundance of plaques (amyloid-beta)An overabundance of tangles (tau protein)Enlargement of the hippocampus Brain atrophy 65. A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply)Routine blood work will be required Follow a strict low-sodium diet Dependency can occur with this medication Drink adequate amounts of fluid daily Do not participate in strenuous activity in the heat 66. A client diagnosed with bipolar disorder has recently started taking lamotrigine as part of their medication regimen. Which of the following would be an essential teaching point to include regarding the medication?It is important for you not to become pregnant while taking this medication You will need to monitor your sodium intake closely while on this medication If you experience a rash, you should notify your physician You will need to monitor your weight while taking this medication 67. During the admission process an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?Akathisia Agnosia  Aphasia Anhedonia 68. A client with schizophrenia has received a standard antipsychotic for a year. His hallucination is less intrusive, but the client remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms. The nurse might expect the psychiatrist to prescribe which medication?HaloperidolDiphenhydramine  Chlorpromazine  Olanzapine  69. The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?Encourage participation in a group card game Encourage participation in various physical activities Encourage participation in a bingo game Encourage the creation of a new interactive game for a unit 70. A client's nursing care plan includes monitoring for auditory hallucinations. Which finding suggests the client may be hallucinating? Darting eyes, title head, and mumbling to self Performing rituals and avoiding open places Elevated mood, hyperactivity, and distractibility Aloofness, haughtiness, and suspect71.  The nurse is building a discharge teaching plan diagnosed with substance use disorder. Which of the following relapse prevention strategies will be included in the teaching? (select all that apply)Attend outpatient and community support groups for addictionEstablish a healthy sleeping eating, and exercise routinePrevent overscheduling and become fatigued and exhausted Reach out to reconnect with old buddies to test strength in resistance Schedule plenty of quiet, unstructured alone time, for television Have a friend or counselor number to call when having doubts 72.  A client is admitted to the hospital for alcohol intoxication. The family reports that he is a drinking addict and has been admitted several times for alcohol detoxification. When can the nurse expect to observe the first symptoms of withdrawal?Within 8 hours Within 24 hours Within 48 hours Within 72 hours73. The nurse has just finished a shift report on an inpatient psychiatric unit. Which of the following clients will the nurse assess first?A client with bipolar disorder is prescribed lithium carbonate and fluoxetine. The morning lab report a lithium level of 0.6 mmol/LA client with schizophrenia prescribed risperidone and paraoxitine scheduled for discharge with a case management referralA client with bipolar disorder was prescribed lithium carbonate who woke this morning slurring words and having difficulty ambulating to the bathroom A client withdrawing from opioid addiction reporting an escalation in anxiety to a moderate level and insomnia74. Which nursing documentation entry accurately describes a client's use of confabulation?Nonverbals indicate communication with unseen othersAttempts to communicate by using rhyming wordsRambles about early childhood experience jumping from topic to topic Verbalizes happiness about a trip to part which was not based in fact75. A client is prescribed risperidone 4 mg PO twice daily. After the client is caught, cheque medication is prescribed. Available is risperidone 0.5mg/ml. How many milliliters would be administered daily? (Write the number only. Do not include labels. Record the answer to the nearest whole number. Do not use a trolling zero.        Health ScienceScienceNursingNURS 2488Share Question
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Question Answered step-by-step Discuss the scope of practice for advance practice nurses, and...  Discuss the scope of practice for advance practice nurses, and prescriptive authority requirement in South Carolina. Identified a plan for how requirements will be met upon graduation. Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)
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