Nursing Questions And Answers

21⟩ Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurses best response is

* A. I understand that god’s voice is real to you, but I do not hear anything. I will stay with you.

* B. The voices are part of your illness; it will stop if you take medication

* C. the voices are all in your imagination, think of something else and till go away

* D. Do not think of anything right now, just go, and relax.

A. I understand that god’s voice is real to you, but I do not hear anything. I will stay with you.

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22⟩ In assessing a clients suicide potential, which statement by the client would give the nurse the highest cause for concern?

* A. My thoughts of hurting my self are scary to me

* B. I would like to go to sleep and not wake up

* C. I have thought about taking pills and alcohol until I pass out

* D. I would like to be free from all these worries

C. I have thought about taking pills and alcohol until I pass out

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23⟩ A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?

* A. Complains of dry mouth

* B. State he feels restless in his body

* C. Stops pacing and sits with the nurse

* D. Exhibits increase activity and speech

C. Stops pacing and sits with the nurse

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24⟩ A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on

* A. borderline personality disorder

* B. anxiety disorder

* C. schizophrenia

* D. depression

C. schizophrenia

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25⟩ A decision is made to discharge a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to

* a. Hold a job.

* b. Relate to his peers.

* c. Perform activities of daily living.

* d. Behave in an outwardly normal

c. Perform activities of daily living.

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26⟩ A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurses highest priority in assessing the client on admission would be to ask him

* A. How he sleeps at night.

* B. If he is thinking about hurting himself

* C. About recent stresses

* D. How he feels about himself

B. If he is thinking about hurting himself

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27⟩ The nurse should know that the normal therapeutic level of lithium is

* A. .6 to 1.2 meq/L

* B. 6 to 12 meq/L

* C. .6 to .12 cc/ml

* D. .6 to .12 cc3/L

A. .6 to 1.2 meq/L

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28⟩ If a Patient complaints about vomiting, diarrhea, and restlessness after taking lithane, then the nurses initial intervention is

* a. Recognize that this is a sign of toxicity and withhold the next medication.

* b. Notify the physician.

* c. Check V/S to validate patient’s concerns

* d. Recognize that this is a normal side effect of lithium and continue the drug.

a. Recognize that this is a sign of toxicity and withhold the next medication.

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29⟩ The client is taking Tofranil. The nurse should closely monitor the patient

* a. Hypertension

* b. Hypothermia

* c. Increase Intra Ocular Pressure

* d. Increase Intra Cranial Pressure

c. Increase Intra Ocular Pressure

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30⟩ A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges

* A. The client to be decompensates and in need have being readmitted to the hospital

* B. The client to need an adjustment or increase in his dose of antidepressant

* C. The depression to be improving and the suicidal ideation to be lessening

* D. The presence of suicidal ideation to warrant a telephone call to the client's physician

C. The depression to be improving and the suicidal ideation to be lessening

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31⟩ The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft.

* A. Zoloft causes erectile dysfunction in men.

* B. Zoloft causes postural hypotension

* C. Zoloft increases appetite and weight gain

* D. It may take 3-4 weeks before client will start feeling better.

A. Zoloft causes erectile dysfunction in men.

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32⟩ After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs

* a. Dystonia

* b. Akathisia

* c. Parkinsonism

* d. Tardive dyskinesia

b. Akathisia

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33⟩ When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following-

* A. Hypertensive episodes

* B. Extrapyramidal symptoms

* C. Hypersalivation

* D. Oversedation

B. Extrapyramidal symptoms

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34⟩ A client is brought to the hospitals emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms-

* A. Increased heart rate, dilated pupils, and fever

* B. Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion

* C. Decreased respirations, constricted pupils, and pallor

* D. Eye irritation, tinnitus, and irritation of nasal and oral mucosa

C. Decreased respirations, constricted pupils, and pallor

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35⟩ The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse

* A. Gives the medication as ordered

* B. Questions the physician about the order

* C. Questions the dosage ordered

* D. Asks the physician to order benztropine (Cogentin) for the side effects

B. Questions the physician about the order

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36⟩ Which of the following client a statement about clozapine (Clozaril) indicates that the client needs additional teaching?

* A. "I need to have my blood checked once every several months while I’m taking this drug."

* B. "I need to sit on the side of the bed for a while when I wake up in the morning."

* C. "The sleepiness I feel will decrease as my body adjusts to clozapine."

* D. "I need to call my doctor whenever I notice that I have a fever or sore throat."

D. "I need to call my doctor whenever I notice that I have a fever or sore throat."

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37⟩ A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of-

* A. Sodium

* B. Iron

* C. Iodine

* D. Calcium

A. Sodium

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38⟩ The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I am not really better, and I have been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?

* A. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect.

* B. Tell the client to stop taking the medication and to call the physician.

* C. Encourage the client to double the dose of his medication.

* D. Ask the client if he has resumed smoking cigarettes.

A. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect.

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39⟩ The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates

* A. An elevated blood glucose level

* B. Insomnia

* C. Hypertension

* D. Urinary retention

D. Urinary retention

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40⟩ Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?

* a. Electrocardiogram (ECG)

* b. Urine sample for protein

* c. Thyroid scan

* d. Creatinine clearance test

a. Electrocardiogram (ECG)

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48 Nursing Questions And Answers

21⟩ Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurses best response is

22⟩ In assessing a clients suicide potential, which statement by the client would give the nurse the highest cause for concern?

23⟩ A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?

24⟩ A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on

25⟩ A decision is made to discharge a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to

26⟩ A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurses highest priority in assessing the client on admission would be to ask him

27⟩ The nurse should know that the normal therapeutic level of lithium is

28⟩ If a Patient complaints about vomiting, diarrhea, and restlessness after taking lithane, then the nurses initial intervention is

29⟩ The client is taking Tofranil. The nurse should closely monitor the patient

31⟩ The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft.

32⟩ After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs

33⟩ When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following-

34⟩ A client is brought to the hospitals emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms-

35⟩ The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse

36⟩ Which of the following client a statement about clozapine (Clozaril) indicates that the client needs additional teaching?

37⟩ A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of-

39⟩ The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates

40⟩ Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?

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Nursing

Home Medical Nursing

48 Nursing Questions And Answers

21⟩ Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurses best response is

22⟩ In assessing a clients suicide potential, which statement by the client would give the nurse the highest cause for concern?

23⟩ A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?

24⟩ A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on

25⟩ A decision is made to discharge a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to

26⟩ A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurses highest priority in assessing the client on admission would be to ask him

27⟩ The nurse should know that the normal therapeutic level of lithium is

28⟩ If a Patient complaints about vomiting, diarrhea, and restlessness after taking lithane, then the nurses initial intervention is

29⟩ The client is taking Tofranil. The nurse should closely monitor the patient

31⟩ The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft.

32⟩ After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs

33⟩ When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following-

34⟩ A client is brought to the hospitals emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms-

35⟩ The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse

36⟩ Which of the following client a statement about clozapine (Clozaril) indicates that the client needs additional teaching?

37⟩ A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of-

39⟩ The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates

40⟩ Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?

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