Lippincott's Q&A Review for NCLEX-RN

When developing the plan of care for a client with a personality disorder, the nurse plans to primarily assist the client with which of the following. Which of the following behaviors indicates to the nurse that the client diagnosed with avoidant personality disorder is improving.

The Client with an Alcohol-Related Disorder

Administer lorazepam 2 mg IM
Draw blood for a magnesium level
Take vital signs every 15 minutes
Place the client in a quiet room with dimmed lights
Remind the client that he is having withdrawal symptoms and that these will be treated
Administer a dose of lorazepam (Ativan) depending on the severity of the withdrawal symptoms
Assess the client for other withdrawal symptoms
Take the client's vital signs
Chart the details of the episode on the electronic health record

The nurse interprets this information as an indication that the client has experienced which of the following conditions. Which of the following statements by the nurse would be most helpful to the client.

The Client with Disorders Related to Other Addictive Substances

Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal
Immediately place the client on withdrawal precautions
Confirm with the client that she has in fact been using her husband's medications
Assess the client for prior and current use of any other substances
Transfer the client to the psychiatric unit
Monitor cardiac and respiratory status
Place seizure pads on the bed
Administer IM haloperidol (Haldol) as prescribed

After administering naloxone (Narcan), an opioid antagonist, the nurse should closely monitor the client for which of the following. When developing the client's care plan, which of the following measures must the nurse include.

The Client with Anxiety Disorders and Anxiety-Related Disorders

Teach problem-solving strategies
Ask the client to deep breathe for 2 minutes
Discuss the client's feelings in more depth
Reduce environmental stimuli
Remind him that any feelings and problems he is having are typical in his current situation
Ask him to talk about his upsetting experiences
Remove any weapons and dangerous items he has in his possession
Acknowledge any injustices/unfairness related to his experiences and offer empathy and support
Ask the client about the stepdad possibly abusing younger children in the family
Ask the client to be specific about what he means by “screwed up.”
Ask the client to sign a No Harm Contract related to suicide and self- mutilation
Ask the client to talk about appropriate ways to express anger toward his mother

While a client is taking alprazolam (Xanax), which of the following should the nurse instruct her to avoid. The nurse suggests that which of the following activities will help the client express her feelings.

The Client with a Somatoform Disorder

Allowing the client to talk about the primary health care providers he has seen and the medications he has taken. Which of the following statements indicates to the nurse that the client is making progress toward recovery from a somatoform disorder.

Managing Care Quality and Safety

Monitor the client's safety and place seizure pads on the cart rails
Record the time, duration, and nature of the seizures
Page the ED primary health care provider and prepare to give diazepam (Valium) intravenously
Ask the friend about the client's medical history and current medications
Ask the other clients to leave the room and meet with another nurse
Ask Becky to talk about what happened to her during the group therapy session
Get close to Annie and protect her from injury until she calms down
Ask Annie about what happened to her during the group
Obtain a prescription to place the client in restraints, if needed
Implement constant observation
Monitor vital signs every 15 minutes
Administer haloperidol (Haldol) and lorazepam (Ativan) IM as prescribed
Remind the client that she is in the hospital and the nurse is with her
Chart the client's response to the interventions
The type, dose, and frequency of use of the pain medication by Nurse 2
The importance of the two of them going to their supervisor about Nurse 2's recent problems
Nurse 1's genuine concern about Nurse 2, her pain, and behaviors
Nurse 1's suspicion that Nurse 2 may be using a client's pain medication for herself
Contact the security department
Obtain an EKG
Initiate a referral to obtain drug rehabilitation counseling
Obtain a prescription for a urine sample

Remind the client that she is in the hospital and that the nurse is with her. A client with a history of cocaine abuse receives intravenous therapy and leaves the hospital "to visit a friend." The client returns to the nursing unit an hour later, agitated, aggressive, combative, and reports “chest pain.”

The Client with a Personality Disorder

Talk with the client about his self-esteem and his fears
Teach the client anxiety management and social skills
Help the client make a list of small group activities at the center he would find interesting
Ask the client to join one of his chosen activities with the nurse and two other clients
Monitor for suicide and self-mutilation
Monitor sleeping and eating behaviors
Discuss the issues of loneliness and emptiness
Discuss her housing options for after discharge

By attending an activity with the nurse, the client can slowly become involved with others. The nurse attempts to help the client clarify true feelings and learn to express them appropriately.

The Client with an Alcohol-Related Disorder

Place client in a quiet room with dimmed lights
Administer lorazepam 2 mg IM 2. Draw blood for a magnesium level
Take the client's vital signs depending on the severity of the withdrawal symptoms
Administer a dose of lorazepam (Ativan)

Therefore, it is best to let the client sleep off the effects of the alcohol. The nurse should assess vital signs to assess the physiological status of the client and the response to medication.

The Client with Disorders Related to Other Addictive Substances

Amphetamine overdose can cause cardiac arrhythmias and respiratory collapse; the nurse should next monitor the client. When the client is medically stable, the nurse may transfer the client to a psychiatric unit. Oral medication may be necessary if the client's anxiety is prolonged or does not decrease with the nurse's interventions.

The nurse should invite the client who is anxious to participate in an activity that involves gross motor movements. Acknowledging the client's frustration, pain, and urges is important in reducing the client's anger.

The Client with Anxiety Disorders and Anxiety- Related Disorders

Ask the client about the step-dad possibly abusing younger children in the family
Record the time, duration and nature of the seizures
Administer haloperidol (Haldol) and lorazepam (Ativan) IM as prescribed 3. Monitor vital signs every 15 minutes
The importance of the two of them going to their supervisor about Nurse
TEST 4: Stress, Crisis, Anger, and Violence

Telling the client to stay in the house to eliminate panic attacks is not correct or helpful. Acknowledging the unfairness of the client's situation does not meet the client's needs at this time. The nurse should work with the client later to slowly set limits on the frequency of the action.

The nurse should then be able to assist the client in developing adaptive coping strategies. The nurse must first ensure the safety of the ward and the staff by asking the security service for help.

The Client Managing Stress

When coping becomes dysfunctional enough to require the client to be hospitalized, the nurse should assess the client for the ability to demonstrate which of the following. In a continuous assessment, the nurse should identify the client's thoughts and feelings about a situation, in addition to which of the following. Which of the following client statements indicates that the client has gained insight into his use of the defense mechanism of displacement.

Which of the following is a crucial goal of therapeutic communication when helping the client deal with personal problems and painful feelings. To convey client respect and acceptance, even if not all of the client's behavior is tolerated.

The Client Coping with Physical Illness

A client receiving dialysis directs profanities at the nurse and then abruptly hangs his head and pleads, “Please forgive me. Something just came

The client was found throwing things at the walls and just picked up the phone. I went through all the treatment for nothing.” In what order of priority from first to last should the nurse perform the following interventions. A psychiatric nurse consultation was arranged after the client stated that he was tired of being in and out of the hospital.

I have other options." The nurse would consider consultation with the psychiatric nurse helpful if the client makes which of the following statements.

The Client in Crisis

The nurse recognizes that a client will only be able to be in crisis during which of the following periods. Which of the following, if stated by the client, indicates to the nurse that the client is ready for discharge. Which of the following statements by the father should alert the nurse to the need for a psychiatric consultation?

Help me!" Which of the following should the nurse use as an initial crisis intervention strategy. The nurse should determine that support persons are prepared to help when verbalizing which of the following.

The Client with Problems Expressing Anger

Assisting the client to recognize the early cues that he is angry
Helping the client identify triggers for his anger
Practicing with the client appropriate ways to express his anger
Identifying alternate ways to express his anger

When a client is about to lose control, additional personnel who come to help usually keep their distance from the client unless directed to come closer by the nurse who is talking to the client. The customer is more likely to play if there is an audience, even extra staff. The client is likely to perceive others as closer than they are and feel threatened.

When additional staff are visible, the client is less likely to regain self-control. Which of the following is a priority for a client who is placed in restraints.

The Client with Interpersonal Violence

Call security officers to the unit for the protection of all on the unit
Calmly restate to the client and his brother that the client cannot be released without a primary health care provider's prescription
Quietly ask the other clients and visitors to move to another area of the unit with a staff member
Ask the client's brother to leave the unit quietly when he repeats his demands
Initiate suicide precautions and a no harm contract
Ask the client if she wishes to contact her family while hospitalized
Offer empathy and support and be nonjudgmental and honest with her
Encourage safe verbalizations of her emotions, especially anger

To help the client recover from such torture and abuse, the nurse should suggest which of the following options. The nurse should help the client explore his feelings and move toward a fuller understanding of his options. When the client has hostile outbursts, it is best for the nurse to help her express her feelings.

As the client calms down, the nurse can explore the client's feeling more deeply. It is not appropriate to ask the client to share her experiences in a group of teenagers.

The Client with Problems Expressing Anger

TEST 5: Abuse and Mental Health Problems of Children, Adolescents,

Children and adolescents with behavioral problems Children and adolescents with adjustment disorders Managing Care Quality and Safety.

The Client Experiencing Abuse

In working with a rape victim, which of the following is most important?
Which parental characteristic is least likely to be a risk factor for child abuse?
Interview the teen about how he is handling the divorce, any bullying he may be experiencing, and his current grades
Interview the mother further about the child's early childhood and any potential antecedents to his current behavior
Interview the father about his awareness of his son's behavior and perspective concerning it as well as the relationship between him and
Ask the boy about self-injury, depression, and suicidality in connection with the scars on his wrists

Which of the following should the nurse establish as a victim's ultimate goal in reconstructing his life. The nurse should decide that further counseling is needed if the client expresses which of the following. After a client discloses a history of childhood sexual abuse, the nurse should ask which of the following questions first.

When obtaining a nursing history from parents who are suspected of violence against their child, which of the following characteristics of the parents must the nurse particularly assess. Which of the following observations by the nurse would indicate that a 15-month-old toddler has been abused.

The Adolescent With Eating Disorders

When developing a teaching plan for a high school health class on anorexia nervosa, which of the following should include the nurse as the primary group affected by this disease. The parents of a newly diagnosed 15-year-old with anorexia nervosa meet with the nurse during the admission process. Which of the following comments by the parents should the nurse interpret as typical for a client with anorexia nervosa.

While coaching a youth soccer team, the nurse observed one of the teammates drinking and cleaning up on multiple occasions. A client newly diagnosed with bulimia is attending the nurse-led group at the mental health center.

Children and Adolescents With Behavior Problems

Refer her to the school authorities to address her academic issues so she can graduate next semester
Refer her to a program at the local community college to improve the client's readiness for college and decrease her anxiety
Refer her to an outpatient program that treats clients with chemical dependency issues
Refer her to a psychiatric clinic so she can get an appropriate diagnosis
A DVD player with headphones and favorite games, cartoons, and child films
A favorite stuffed toy animal or other soft toy
A favorite nonelectronic game
Medication that can be given as needed to calm the child
Explain to the family, in terms the child can understand, the benefits of his medication in dealing with school and home problems he is
Explore the parents' attitudes about medication administration in general and their child's medication in particular
Explore the child's reasons for removing the patch during the day rather than at the end of the day
Have the psychiatrist discuss with the child and parents a trial of a different medication

But sometimes I still feel like I'm going to lose control and hurt him.” The nurse should suggest which of the following to the mother. The nurse warns the parents to pay particular attention to which of the following in their son. He thinks the son will "get over it." The mother is concerned that it may negatively affect her son's peer relationships when he gets older.

My brain doesn't turn off at night.” The psychiatrist diagnoses that the child is experiencing attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well as ADHD. Which of the following should the nurse include in the teaching plan for the parents of a child taking methylphenidate (Ritalin).

The Child and Adolescent with Adjustment Disorders

If the child cannot be engaged electronically, a favorite non-electronic toy will be the next choice. Telling the teacher that the nurse cannot believe that the teacher is letting the child get away with the behavior is condescending and condescending. Explore the child's reasons for removing the patch during the day rather than at the end of the day.

First, the child's reasons for removing the patch must be investigated to determine what needs to be done to address the problem of inadequate medication administration. Once the child's and parents' feelings about medication are known, education can be offered to make sure the child understands how the medication can help him do better at school and at home.

The Child and Adolescent With Adjustment Disorders

In addition, the nurse manager must correct any misinformation or misinterpretation that the nurse may have. If you say the nurse sounds burnt out and ask about time off, don't focus on her disappointment or address the inaccuracy of the nurse's statement. Furthermore, adoption by a nurse is inappropriate because it blurs the lines between her professional and personal life and may cause confusion.

The assistant is concerned about the client's behavior and does not know why this is happening, so the nurse should provide some explanation about the issues involved and show empathy for the assistant. It is appropriate to explain that the client is not asking for attention, but the nurse's response does not address the reason for the teen's behavior and is therefore inadequate and sounds a bit like the nurse is denigrating the assistant, which assistant will not encourage you to listen. to what she has to say.

Postreview Tests

COMPREHENSIVE

Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the
Gloves
Goggles
Gown
Mask
The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation
The client with right lower quadrant pain at 10 weeks' gestation
The client who is at term and has had no fetal movement for 2 days
The client from the emergency department at term and screaming loudly because of labor contractions

The nurse assesses that the client is moving properly if the client uses any of the following methods of walking with crutches. The nurse should instruct the client to increase intake of which of the following. The nurse should suspect that a client taking disulfiram (Antabuse) has consumed alcohol when the client exhibits any of the following symptoms.

The nurse teaches the client that this procedure is useful in diagnosing which of the following. The client tells the nurse, "These are my other pain medications." Which of the following statements by the nurse is most appropriate.