HESI Practice Test 75 Preguntas 2021

NURSING MEDSURGE HESI Practice Test 75 Preguntas 2020 A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 d ...

NURSING MEDSURGE HESI Practice Test 75 Preguntas 2020 A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. I will notify the healthcare provider if I have a sore throat or flu-like symptoms. I will continue to take my benztropine mesylate (Cogentin) every day. Rationale Photosensitivity is a side effect of Prolixin and a vacation in a tropical climate increases the client's chance of experiencing this side effect. The nurse should teach the client to avoid direct sun and wear sunscreen. The other client statements do not indicate the need for further teaching. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? Did you really believe you were Jesus Christ? I think you're getting well. Others have had similar thoughts when under stress. Why did you think you were Jesus Christ? Rationale The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? Can your case manager take you to your appointments? Take your medication for anxiety before you ride the bus. Let's talk about what happens when you feel very anxious. What are some ways that you can cope with your anxiety? Rationale An open-ended question that assists the client in problem-solving ways to cope with the anxiety engages the client in self management. The other responses do not allow the client to explore ways to cope with anxiety. The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation? The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn. Rationale Disparity in the parental reports and objective findings of a child's injury provides the most validation. A child's explanation of an injury is often influenced by age, fear, or imagination. The other observations of the parents are not conclusive of child abuse. A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? Encourage the client's self-motivation by asking her to pass trays for the rest of the week. Provide an additional challenge by asking the client to help feed the older clients. Suggest another way for this client to participate in the unit's activities. Tell the client that hospital guidelines allow only staff to pass the trays. Rationale Clients with anorexia should not be allowed to plan or prepare food for unit activities. The nurse should redirect the client's request and encourage the client to participate in another unit activity. The other responses are not indicated. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents? If he has seemed depressed recently. If a drug overdose has ever occurred before. If he might have taken any other drugs. If he has a desire to quit taking drugs. Rationale Knowledge of all substances taken guide further treatment, such as administration of antagonists. The nurse should ask the parents if the adolescent may have taken other drugs. The other assessments are not indicated at this time. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological managment for withdrawal? Client will not demonstrate cross-addiction. Codependent behaviors will be decreased. Excessive CNS stimulation will be reduced. Client's level of consciousness will increase. Rationale Substitution therapy with another CNS depressant is intended to decrease excessive CNS stimulation that can occur during benzodiazepine withdrawal. The other effects are not the expected therapeutic response. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. You're not being poisoned. Why do you think someone is trying to poison you? No one on this unit has ever died from poisoning. You're safe here. I will talk to your healthcare provider about the possibility of changing your diet. Rationale The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated. An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? Encourage the client to actively participate in assigned activities on the unit. Place a lock on the client's closet. Ignore the client's paranoid ideation to extinguish these behaviors. Explain to the client that his suspicions are false. Rationale Diverting the client's attention from paranoid ideation and encouraging the client to complete unit assignments can be helpful in assisting develop a positive self-image. The other actions are not indicated. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? Call a staff member to escort the client to his room. Tell the client to talk to his healthcare provider about his privileges. Remind the client of the unit rules. Calmly address the client's inappropriate behavior. Rationale Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? How can I help? Things probably aren't as bad as they seem right now. Let's talk about what is right with your life. I hear how miserable you are, but things will get better soon. Rationale Offering self shows empathy and caring and is the best response to provide. The other responses do not convey that the nurse is listening to the client's distress. An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? Orient the client to the time, place, and person. Tell the client that the nurse is there and will help her. Remind the client that her mother is no longer living. Explain the seriousness of her injury and need for hospitalization. Rationale Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance. Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, and the other reponses are not likely to help the client's emotional distress. An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? No one is after you, you're safe here. You'll feel better after you have rested. I know you must feel lonely and frightened. Come with me to your room and I will sit with you. Rationale The best response offers support without judgment or demands. The other responses are not therapeutic communication for a client who is hallucinating or experiencing a delusion, which are perceive by this client as a crisis. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? I am the leader today. Would you like to be the leader tomorrow? I will be leading this group. What would you like to accomplish during this time? I have been assigned to be the leader of this group. I will be here for the next six weeks. I am the leader. You seem angry about not being the leader yourself. Rationale Anxiety about participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. The nurse should provide information that focuses the group back to defining its function. The other responses do not focus the group on its purpose or task. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? Acute psychiatric illnesses impair intelligence. Intelligence is influenced by social and cultural beliefs. Poor concentration skills suggests limited intelligence. The inability to think abstractly indicates limited intelligence. Rationale Social and cultural beliefs have significant impact on intelligence. The other factors do not necessarily suggest limited intelligence. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? Notify the healthcare provider immediately and prepare for administration of an antidote. Notify the healthcare provider of the symptoms prior to the next administration of the drug. Record the symptoms as normal side effects and continue administration of the prescribed dosage. Hold the medication and refuse to administer additional amounts of the drug. Rationale Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." Which assessment findi ng should the nurse reference when initiating a referral? Altered thought processes. Moderate levels of anxiety. Inadequate social support. Altered health maintenance. Rationale The nurse should initiate a referral based on anxiety levels and feelings of nervousness that the client described as interfering with sleep, appetite, and the inability to solve problems. The other findings are not indicated based on the client's reported symptoms. The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) Select all that apply Permit rest periods as needed. Speaking slowly and simply. Place the client on suicide precautions. Observe and encourage food and fluid intake. Encourage vigorous exercise and long walks on the unit. Rationale Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state. The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression? Grandiose ideation. Self-destructive thoughts. Suspiciousness of others. A negative view of self and the future. Rationale Negative self-image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression. An adult male who is a sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the client attempting to achieve? Self-Actualization. Loving and Belonging. Basic Needs. Safety and Security. Rationale Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential. The other stages do not focus on this client's statement. Which statement about contemporary mental health nursing practice is accurate? There is one approved theoretical framework for psychiatric nursing practice. Psychiatric nursing has yet to be recognized as a core mental health discipline. Contemporary practice of psychiatric nursing is primarily focused on inpatient care. The psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing is not only concerned with one-on-one interactions. Mental health stressors can impact and be reflected in the overall direction, activities, behaviors, and responses involving families, groups, and entire communities. The other statements are not consistent with mental health nursing. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? Crickets are a good source of protein. I have not heard any voices for a week. Only my belief in God can help me. Sometimes I have a hard time sitting still. Rationale The most frequent cause of increased symptoms in clients who are psychotic is noncompliance with the medication regimen. If the client believes that "God alone" can help, which may be a delusion and not faith-based, the client may discontinue the prescribed medication. The other client statements do not pose the greatest threat to the client's prognosis. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. Which defense mechanism is the client using? Sublimation. Identification. Introjection. Repression. Rationale Identification is an attempt to be like someone or emulate the personality traits of another. The client is not demonstrating the other psychosocial mechanisms. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? Monitor appetite and observe intake at meals. Maintain safety in the client's milieu. Provide ongoing, supportive contact. Encourage participation in activities. A client who is depressed is at risk for suicide.The most important reason for close observation immediately after admission is to maintain safety due to the client's potential risk for self injury. The other interventions are not the priority. An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first? Do you have problems with hallucinations? Are you ever alone when you hear the voices? Has anyone in your family had hearing problems? Do you see things that others cannot see? Rationale Determining if the client is alone when hearing voices will assist in differentiating between hallucinations and hearing loss, which is common in the aging population. Other follow-up questions should then be asked to further validate if the client is experiencing auditory hallucinations. 1. On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate? Clean the unit kitchen cabinets. Participate in a group quilting project. Watch television in the activity room. Bake a cake for a resident's birthday. Rationale Peer interaction in a group activity that is identified by the client has a hobby or diversion helps to engage the client with others, which prevents social isolation and withdrawal. The other activities do not involve peer interaction and may promote social isolation. The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make? Clara Barton was not your nurse. What did she do to you that was so mean? I didn't know that Clara Barton was a nurse. Clara Barton started the American Red Cross. Rationale The historical fact that Clara Barton was a nurse during the Civil War is referencing the concept of universality in this group therapy discussion. Stating the original role of Clara Barton in nursing should be presented, which is the reality in nursing and the American culture. The other responses are not indicated. At a support meeting for parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? Addiction is a chronic, incurable disease. Tolerance to the effects of drugs causes feelings of depression. Feelings of depression frequently lead to drug abuse and addiction. Careful monitoring should be provided during withdrawal from the drugs. Rationale The priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide. The other responses are not indicated. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? Plan an outing with the peer group within the first week of admission. Distract the client whenever discomfort about being with others is expressed.. Confront fears and discuss the possible causes of these fears with the client. Accompany the client outside for an increasing amount of time each day. Rationale The process of gradual desensitization by controlled exposure to the situation which is feared, is the treatment of choice in phobic reactions. The other options are not indicated in the initial phase of desensitization. An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? Encourage the client to actively participate in assigned activities on the unit. Place a lock on the client's closet. Ignore the client's paranoid ideation to extinguish these behaviors. Explain to the client that his suspicions are false. Rationale Diverting the client's attention from paranoid ideation and encouraging the client to complete unit assignments can be helpful in assisting develop a positive self-image. The other actions are not indicated. An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first? Do you have problems with hallucinations? Are you ever alone when you hear the voices? Has anyone in your family had hearing problems? Do you see things that others cannot see? Rationale Determining if the client is alone when hearing voices will assist in differentiating between hallucinations and hearing loss, which is common in the aging population. Other follow-up questions should then be asked to further validate if the client is experiencing auditory hallucinations. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to which client assessment finding? early childhood experiences involving authority issues. anger about being hospitalized. erroneous interpretation of reality. phobic fear of food. Rationale Psychotic clients have difficulty with trust and interpreting reality. Nursing care should be directed at building trust and promoting an accurate reality. Activities with limited concentration and no competition should be encouraged in order to build self-esteem. The other assessment findings are not specifically related to the development of delusions. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? The emergency room nurse. His case manager. The clinic healthcare provider. His support group sponsor. Rationale The case manager is responsible for coordinating community services. Since this client has a dual diagnosis, the nurse should refer the client to the case manager to explore available treatment options. The other referrals are not indicated. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. You're not being poisoned. Why do you think someone is trying to poison you? No one on this unit has ever died from poisoning. You're safe here. I will talk to your healthcare provider about the possibility of changing your diet. Rationale The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities. The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities. The nurse should report any case of suspected child abuse to the nurse in charge. The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked. Rationale It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? Decreased thyroid stimulating hormone level. Elevated liver function profile. Increased white blood cell count. Decreased hematocrit and hemoglobin levels. Rationale Hyperthyroidism causes an increased level of serum thyroid hormones (T3and T4), which inhibit the release of thyroid stimulation hormone (TSH). The nurse should notify the healthcare provider of the decreased TSH level, which may influence the client' s mood swings and behaviors. The other findings are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.) Select all that apply Compulsions relieve anxiety. Anxiety is the key reason for OCD. Obsessions cause compulsions. Obsessive thoughts are linked to levels of neurochemicals. Antidepressant medications increase serotonin levels. Rationale To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomatology. Compulsions are behaviors that help relieve anxiety, which is a vague feeling related to unknown fears, that motivate behavior to help the client cope and feel secure. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals, particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI). All obsessions do not result in compulsive behavior. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? Dementia. Depression. Schizophrenia. Chronic brain syndrome. Rationale The client is demonstrating disorganized speech that may include word salad using both real and imaginary words in no logical order, incoherent speech, and clanging (rhyming), which are positive symptoms of schizophrenia. The other syndromes are not manifested by word salad, clanging, or neologisms. An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? Place the client on seizure precautions and monitor carefully. Immediately transfer the client to intensive care unit. Describe the symptoms to the charge nurse and record on the client's chart. No action is required at this time as these are known side effects of such drugs. Rationale These symptoms are descriptive of a life threatening reaction to neuroleptic drugs, known as neuroleptic malignant syndrome (NMS) which is manifested by fever, rigidity, autonomic instability, and encephalopathy. This is an emergency reaction, and the client requires immediate critical care. The other actions do not address the potential of respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure that can result in death due to NMS. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? Perphenazine (Trilafon). Diphenhydramine (Benadryl). Chlordiazepoxide (Librium). Isocarboxazid (Marplan). Rationale Librium, an antianxiety drug as well as other benzodiazepines, is used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. The other medications are not indicated for benzodiazepine withdrawal. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? Remind the client that his suspicions are not true. Ask one nurse to spend time with the client daily. Encourage the client to participate in group activities. Assign the client to a room closest to the activity room. Rationale A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily, which is likely to be therapeutic for this client. The other actions are too stressful for the client and not indicated. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? Notify the healthcare provider immediately and prepare for administration of an antidote. Notify the healthcare provider of the symptoms prior to the next administration of the drug. Record the symptoms as normal side effects and continue administration of the prescribed dosage. Hold the medication and refuse to administer additional amounts of the drug. Rationale Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? Let me call and leave a message for your healthcare provider. The healthcare provider should be here on Monday morning. How can I help answer your questions? What concerns do you have at this time? Rationale Clients have the right to information about their treatment. The nurse should reassure the client that a call to notify the healthcare provider will be readily placed. The other responses are not the highest priority intervention. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. You're not being poisoned. Why do you think someone is trying to poison you? No one on this unit has ever died from poisoning. You're safe here. I will talk to your healthcare provider about the possibility of changing your diet. Rationale The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? Remind the client that his suspicions are not true. Ask one nurse to spend time with the client daily. Encourage the client to participate in group activities. Assign the client to a room closest to the activity room. Rationale A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily, which is likely to be therapeutic for this client. The other actions are too stressful for the client and not indicated. The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? Your healthcare provider has prescribed ambulation on the first postoperative day. You must ambulate to avoid complications which could cause more discomfort than ambulating. I know how you feel. You're angry about having to ambulate, but this will help you get well. I'll be back in 30 minutes to help you get out of bed and walk around the room. Rationale Telling the adolescent that the nurse will be back in 30 minutes provides a "cooling off" period, is firm, direct, non-threatening, and avoids arguing with the client. The other responses are not therapeutic. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? Reassure the client that no one will harm her while she is in the hospital. Ask the healthcare provider to give the client the medication. Explain that the diabetic medication is important to take. Reassess client's mental status for thought processes and content. Rationale The most important intervention is to reassess the client's mental status and to take further action based on the findings of this assessment. The other interventions are not likely to help a client who is having false beliefs. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? The emergency room nurse. His case manager. The clinic healthcare provider. His support group sponsor. Rationale The case manager is responsible for coordinating community services. Since this client has a dual diagnosis, the nurse should refer the client to the case manager to explore available treatment options. The other referrals are not indicated. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents? If he has seemed depressed recently. If a drug overdose has ever occurred before. If he might have taken any other drugs. If he has a desire to quit taking drugs. Rationale Knowledge of all substances taken guide further treatment, such as administration of antagonists. The nurse should ask the parents if the adolescent may have taken other drugs. The other assessments are not indicated at this time. An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? No one is after you, you're safe here. You'll feel better after you have rested. I know you must feel lonely and frightened. Come with me to your room and I will sit with you. Rationale The best response offers support without judgment or demands. The other responses are not therapeutic communication for a client who is hallucinating or experiencing a delusion, which are perceive by this client as a crisis. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing problem for discharge planning? Ineffective denial related to situational anxiety. Ineffective coping related to inadequate support. Social isolation related to difficult interactions. Self-care deficit related to cognitive impairment. Rationale The client is unable to acknowledge the move to a boarding home, which is related to denial related to situational anxiety. the other problem statements may also be indicated but the client's use of denial as a defense mechanism keeps the client from dealing with his feelings about living arrangements. Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? Talk to the client outside the group about his behavior during group meetings. Remind the client to allow others in the group a chance to talk. Allow the group to handle the problem. Ask the client to join another group. Rationale The phase the group process is in--initial, working, or termination--this will help determine communication styles between the group members. After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to address the situation. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? Hamburger, French fries, and chocolate milkshake. Liver and onions, broccoli, and decaffeinated coffee. Pepperoni and cheese pizza, tossed salad, and a soft drink. Roast beef, baked potato with butter, and iced tea. Rationale Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a hypertensive crisis that is life-threatening. Roast beef, potatoes, butter, and tea do not contain tyramine. The other selections contain tyramine and should be avoided by the client who is taking Parnate. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug? My mouth feels like cotton. That stuff gives me indigestion. This pill gives me diarrhea. My urine looks pink. Rationale A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? Reassure the client by telling him that his fear of the admission procedure is to be expected. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. Assess the content of the hallucinations by asking the client what he is hearing. Ignore the behavior and make no response at all to his delusional statements. Rationale Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill himself or the nurse. The other actions are not indicated. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best behavioral interpretation of the mother's statements? Regressing to an earlier behavior pattern. Sublimating anger. Projecting feelings onto the nurse. Suppressing fear. Rationale Projection is attributing one's own thoughts, impulses, or behaviors onto another--it may be the mother who might be harming the child and she is attributing her actions to the nurse. The other evaluations are not the most likely based on the child's history of previous injuries. The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation? -The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. -The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. -The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. -The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn. Rationale Disparity in the parental reports and objective findings of a child's injury provides the most validation. A child's explanation of an injury is often influenced by age, fear, or imagination. The other observations of the parents are not conclusive of child abuse. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include? It may take 3 to 4 weeks to achieve therapeutic effects. Keep your dietary salt intake consistent. Avoid eating aged cheese and chicken liver. Eat foods high in fiber such as whole grain breads. Rationale The effectiveness of Lithium is influenced by salt intake, so the client should maintain a consistent amount of salt intake. Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to be excreted, potentially resulting in toxicity. The other instructions are not specific to teaching about lithium carbonate (Lithonate). An adult male who is a sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the client attempting to achieve? Self-Actualization. Loving and Belonging. Basic Needs. Safety and Security. Rationale Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential. The other stages do not focus on this client's statement. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? Decreased thyroid stimulating hormone level. Elevated liver function profile. Increased white blood cell count. Decreased hematocrit and hemoglobin levels. Rationale Hyperthyroidism causes an increased level of serum thyroid hormones (T3and T4), which inhibit the release of thyroid stimulation hormone (TSH). The nurse should notify the healthcare provider of the decreased TSH level, which may influence the client' s mood swings and behaviors. The other findings are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? Monitor appetite and observe intake at meals. Maintain safety in the client's milieu. Provide ongoing, supportive contact. Encourage participation in activities. Rationale A client who is depressed is at risk for suicide.The most important reason for close observation immediately after admission is to maintain safety due to the client's potential risk for self injury. The other interventions are not the priority. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature 100o F, pulse 100 beats/minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem? Risk for injury related to suicidal ideation. Risk for injury related to alcohol detoxification. Knowledge deficit related to ineffective coping. Health seeking behaviors related to personal crisis. Rationale The most important client problem is alcohol detoxification because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety is the priority, and the risk for injury should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The other problems are not the priority. An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? Place the client on seizure precautions and monitor carefully. Immediately transfer the client to intensive care unit. Describe the symptoms to the charge nurse and record on the client's chart. No action is required at this time as these are known side effects of such drugs. Rationale These symptoms are descriptive of a life threatening reaction to neuroleptic drugs, known as neuroleptic malignant syndrome (NMS) which is manifested by fever, rigidity, autonomic instability, and encephalopathy. This is an emergency reaction, and the client requires immediate critical care. The other actions do not address the potential of respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure that can result in death due to NMS. An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide? Anywhere you want to stand as long as you do not get hurt by those in the parade. You are confused because of all the activity in the hall. There is no parade. Let's go back to the activity room and see what is going on in there. Remember I told you that this is a nursing home and I am your nurse. Rationale It is common for those with Alzheimer's disease (AD) to use the wrong words. Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful because clients with AD experience short-term memory loss. The other responses dismiss the client's attempt to find order, do not help her relate to the surroundings, and are frustrating which increase anxiety level. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? Menstruation onset at age 9. Contraceptive method includes condoms only. Menstrual cycle occurs every 35 days. "Black-out" after one drink last night on a date. Rationale A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up at this time. The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? Loss of independence. Increased self-understanding. Isolation from society. Development of intimate relationships. Rationale Middle adulthood is characterized by self-reflection, understanding, acceptance, and generativity or guidance of children. The other developmental tasks are not specific to middle adulthood. he nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression? Grandiose ideation. Self-destructive thoughts. Suspiciousness of others. A negative view of self and the future. Rationale Negative self-image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression.