A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of

the following treatment approaches should the nurse plan to take?

Maintain close observation of the client.

A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should

the nurse expect?

The client is able to identify the names of family members.

A nurse is caring for a client who reports that the television set in the room is really a two-way radio and

states, "voices are coming from the TV and everything we say in this room is being recorded." Which of

the following responses should the nurse make?

"That must be very frightening."

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute

mania. Which of the following client goals should the nurse identify as the priority?

Maintaining adequate hydration

A nurse is preparing to administer a benzodiazepine to a client who has generalized anxiety disorder. The

nurse should tell the client to expect which of the following adverse effects?

Sedation

A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted

injuries. The nurse should identify which of the following interventions as the priority when planning

care for this client?

Promoting and maintaining client safety

A nurse is providing teaching to a client who has a new prescription for disulfiram for the management

of alcohol dependence. Which of the following dietary choices should the nurse instruct the client to

avoid?

Pure vanilla extract

A nurse is planning care for a client who has a physical dependence to alprazolam and must discontinue

the medication. Which of the following actions should the nurse include in the plan?

Taper the medication gradually overseveral weeks.

A nurse is caring for a newly admitted client who is receiving treatment for alcohol use disorder. The

client tells the nurse, "I have not had anything to drink for 6 hours." Which of the following findings

should the nurse expect during alcohol withdrawal?

Insomnia

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following

medications should the nurse expect to administer during this phase of the client's care?

Diazepam

A nurse is speaking to a community group about the diagnosis and treatment of clients who have

Alzheimer's disease. The nurse should conclude that member of the group requires further teaching

when she identifies which of the following findings as a manifestation of Alzheimer's disease?

Sudden confusion

A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for

buspirone. The nurse should inform the client that which of the following manifestations is a common

adverse effect of this medication?

Dizziness

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for

lithium. The nurse should identify that it is safe to administer which of the following medications while

the client is taking lithium?

Valproic acid

A nurse in the emergency department is caring for a toddler who has a fractured arm. Which of the

following findings should the nurse identify as a possible indication of physical abuse?

The parent provides a history that is inconsistent with the child's injury.

A nurse is evaluating the plan of care for a client who has antisocial personality disorder. Which of the

following client actions indicatesthat he is making progress with the treatment? (Select all that apply.)

Assisting another client who has depression to fill out a menu

Requesting a weekend pass to go home

A nurse is providing teaching to a client who is to start taking valproic acid. Which of the following

instructions should the nurse include?

"You should have your liver function levels monitored regularly while taking valproic acid"

A nurse is teaching a client who has agoraphobia about systematic desensitization. Which of the

following comments should the nurse include in the teaching?

"You will slowly be exposed to increasing levels of public spaces."

A nurse is planning a staff education session about the administration of antidepressant medications to

older adult clients. Which of the following information should the nurse include in the teaching?

Older adult clients require a lower initial dose of antidepressant medication than adult clients.

A nurse in an acute mental health facility is reviewing the medication records for a group of clients. The

nurse should expect a prescription for memantine for a client who has which of the following diagnoses?

Severe Alzheimer's disease

A nurse is assessing a client who has binge-eating disorder. Which of the following findings should the

nurse expect?

Abdominal pain

A nurse on an acute care unit is providing postoperative care to an older adult client who develops

delirium. Which of the following actions should the nurse take?

Request a prescription for an antianxiety medication.

A nurse is assessing a client who has conduct disorder. Which of the following findings should the nurse

expect?

Aggressive behavior toward others

A nurse in an acute mental health facility is leading a nursing staff discussion about the legal aspects of

involuntary admissions. Which of the following information should the nurse include?

An involuntary admission is justified if the client is a danger to others.

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and

down the hall very rapidly and muttering in an angry manner. Which of the following actions should the

nurse take first?

Approach the client in a nonthreatening manner.

A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine. For

which of the following findings should the nurse question the provider's prescription?

Hypotension

A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity

disorder (ADHD). Which of the following instructions should the nurse include in the teaching?

"Ignore your child's attention-seeking behaviorsthat are not dangerous."

A nurse is interviewing a client who has anorexia nervosa. Which of the following findings should the

nurse expect?

Strenuous exercise regimen

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to

attend group therapy today." Which of the following responses should the nurse make?

"Attending group therapy, even if you're tired, is an important part of your treatment."

A nurse is performing an admission assessment for a client who hasrestricting type anorexia nervosa.

The nurse should expect which of the following findings?

Decreased caloric intake

A nurse in a substance use disorder treatment facility is reviewing the medication records for a group of

clients. The nurse should expect to administer methadone for a client who has a substance use disorder

for which of the following substances?

Opiates

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following

initial reactions should the nurse expect from the client?

Denial

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning

hygiene care. Which of the following actions should the nurse take?

Talk to the client from two arm-lengths away.

A nurse is assessing a client who takes phenelzineu for the treatment of depression. Which of the

following findings is the priority for the nurse to report to the provider?

Elevated blood pressure

A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following

findings should the nurse report to the provider as an indication of rape-trauma syndrome?

Report of intense guilt

A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the

following techniques should the nurse use?

Avoid a nonjudgemental tone.

A nurse is providing teaching to the family of a client who has Alzheimer's disease about donepezil.

Which of the following statements should the nurse include in the teaching?

"Donepezil can improve cognitive functioning during the earlier stages of the disease."

A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy

(ECT). Which of the following findings should the nurse identify as a potential complication of the

procedure?

Cardiac arrhythmia

A nurse is planning care for a client who has bipolar disorder and is experiencing manic episode. Which

of the following interventions should the nurse include in the plan?

Provide the client frequently with high-calorie finger-foods.

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic

episode. Which of the following actions is the nurse's priority?

Protect the client from impulsive behavior.

A nurse in an acute mental health facility is planning care for a client who has obsessive-compulsive

disorder (OCD). Which of the following actions should the nurse include in the plan?

Instruct the client to practice thought stopping.

A nurse is caring for a client who has alcohol use disorder. Following alcohol withdrawal, which of the

following medications should the nurse expect to administer to the client during maintenance?

Disulfiram

A nurse is caring for a client who attends family counseling with his partner and their children. The client

tells the nurse that he isn't going to attend any further sessions and states, "I don't have time for all that

talking." Which of the following responses should the nurse make?

"It must be difficult for you to talk about family problems."

A nurse in an acute substance disorder unit is assessing a client who received treatment in the

emergency department for a heroin overdose. Which of the following findings should the nurse

anticipate during heroin withdrawal?

Muscle aches

A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following

findings should the nurse expect?

Dilated pupils

A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is

admitted under court order following the theft and destruction of a car. Which of the following behaviors

should the nurse expect the client to display?

Anger with the nursing staff for hospitalizing him against his will

A nurse is developing a plan of care for a client who has anorexia nervosa. The nurse should identify that

which of the following actions is contraindicated for this client?

Permitting the client to spend some quiet time alone after each meal

A nurse in the emergency department is assessing a client who has heroin intoxication. Which of the

following findings should the nurse expect?

Respiratory depression

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of

the following actions should the nurse take?

Administer the medication at bedtime.

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the

following techniques should the nurse use to facilitate communication with the client?

Speak to the client using simple and concrete terminology.